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THE 


HYGIENE  OF  THE  SICK-ROOM; 


A   BOOK   FOR 


NURSES   AND   OTHERS, 


BRIEF  CONSIDERATION  OF  ASEPSIS,  ANTISEPSIS,  DISINFEC- 
TION, BACTERIOLOGY,  IMMUNITY,  HEATING  AND  VENTI- 
LATION, AND  KINDRED  SUBJECTS,  FOR  THE  USE  OF 
NURSES   AND    OTHER    INTELLIGENT  WOMEN. 

* 

1-003 
BY 

WILLIAM  BUCKINGHAM  CANFIELD,  A.M.,  M.D., 

LECTURER  ON  CLINICAL  MEDICINE  AND  CHIEF  OF  CHEST  CLINIC,  UNIVERSITY 

OF  MARYLAND;   VISITING  PHYSICIAN  TO   BAY  VIEW  HOSPITAL; 

VISITING  PHYSICIAN  TO  THE  UNION  PROTESTANT 

INFIRMARY,    ETC.,   BALTIMORE. 


*  #      _ 


PHILADELPHIA: 
P.    BLAKISTON,    SON    &    CO., 

1012     WALNUT    STREET. 
1892. 


9414 


COPYRIGHT,  1892,  BY  P.  BLAKISTON,  SON  &  Co. 


PRESS  OF  WM.  F.  FELL  &  Co., 
I22O-24  SANSOM  ST., 

PHILADELPHIA. 


PREFACE. 


This  manual  is  the  outcome  of  a  series  of  lec- 
tures delivered  before  the  University  of  Maryland 
Training  School  for  Nurses.  Its  object  is  not  to 
give  a  course  in  bacteriology,  but  to  show  in  a 
clear  way  the  connection  between  bacteria  and 
disease,  and  how  we  may  prevent  the  latter,  by 
destroying  as  far  as  possible,  the  former.  The 
subject,  being  a  new  department  of  medicine,  is 
necessarily  undergoing  many  changes.  Things 
which  are  true  to-day  may  be  replaced  to-morrow 
by  stronger  facts  ;  therefore,  while  the  author  has 
tried  as  far  as  possible,  to  adhere  to  facts,  and  not 
indulge  in  fancies,  it  may  be  that  he  has  made 
statements  to  which  others  might  take  exception, 
or  to  which  they  would  not  agree.  At  all  events 
he  has  tried  to  state  the  truth,  and  if  by  chance  he 
should  have  exaggerated  the  dangers  of  these 
bacteria,  he  hopes  it  will  only  serve  to  make  the 
nurse  more  careful  in  her  daily  work. 

W.  B.  C. 

iota  North  Charles  Street,  Baltimore. 
September,  1892. 

iii 


CONTENTS. 


PAGE 

Introduction, 9 

CHAPTER  I. 
Bacteriology, n 

CHAPTER  II. 
Infection  and  Disinfection, 27 

CHAPTER  III. 
Tuberculosis, 65 

CHAPTER  IV. 
Typhoid  Fever 76 

CHAPTER  V. 
Typhus  Fever, * 85 

CHAPTER  VI. 
Asiatic  Cholera, 87 

CHAPTER  VII. 
Scarlet  Fever, 93 

CHAPTER  VIII. 
Measles, 103 

CHAPTER  IX. 
Diphtheria, 107 

CHAPTER  X. 
Smallpox, 128 

CHAPTER  XI. 

Yellow  Fever, 131 

V 


CONTENTS. 


CHAPTER  XII.  PAGE 

Epidemic  Influenza, 133 

CHAPTER  XIII. 
Pneumonia, 136 

CHAPTER  XIV. 
Whooping  Cough, 139 

CHAPTER  XV. 
Malaria, 141 

CHAPTER  XVI. 

The  Bacteria  of  Surgical  Diseases, 146 

CHAPTER  XVII. 

The  Bacteria  of  the  Mouth, 174 

CHAPTER  XVIII. 
Ophthalmia  Neonatorum, 182 

CHAPTER  XIX. 
Ventilation  and  Heating, 188 

CHAPTER  XX. 
Immunity  and  Protection  from  Disease, 213 

CHAPTER  XXI. 
Food, 230 

Index 243 


AUTHORITIES. 


Parkes'  Manual  of  Practical  Hygiene. 

The  Story  of  the  Bacteria.     T.  M.  Prudden. 

Dust  and  its  Dangers.     T.  M.  Prudden. 

Fever-Nursing.    J.  C.  Wilson. 

Surgical  Bacteriology.     N.  Senn. 

Aseptic  and  Antiseptic  Surgery.    Arpad  G.  Gerster. 

Disinfection  and  Disinfectants ;  their  Application  and  Use 
in  the  Prevention  and  Treatment  of  Disease,  and  in 
Public  and  Private  Sanitation.  By  the  Committee  on 
Disinfectants,  Appointed  by  the  American  Public  Health 
Association. 

Shakespeare's  Report  on  Cholera  in  Europe  and  India. 

Les  Bacteries.     Cornil  et  Babes. 

Agnew's  Surgery.    Second  Edition. 

Diseases  of  Children.    J.  Lewis  Smith. 

Rone's  Hygiene. 

Fagge's  Practice  of  Medicine. 

Fliigge.     Die  Mikro-organismen. 

Canfield's  Translation  of  Seifert  and  Miiller's  Manual  of 
Clinical  Diagnosis. 

Wm.  H.  Welch.  Extracts  from  Articles  on  Modes  of  In- 
fection, Diphtheria,  and  other  Subjects 

Loomis's  Practical  Medicine. 

The  Relation  of  Bacteria  to  Practical  Surgery.  John  B. 
Roberts. 

Uffelmann.     Hygiene. 

Wm.  Osier.     Practice  of  Medicine. 

Hiram  Woods.     Blindness  in  the  United  States. 

Keating's  Cyclopaedia  of  the  Diseases  of  Children, 
vii 


Hygiene  of  the  Sick-Room. 


INTRODUCTION. 

It  has  long  been  conceded  that  skilled  and  trained 
labor  of  any  kind  accomplishes  more  good  than 
ordinary  unskilled  labor.  The  physician  has  for 
years  been  trained  and  drilled  in  his  work  before 
starting  on  his  life's  career,  while  his  most  impor- 
tant assistant,  the  nurse,  was,  until  very  recently,  a 
woman  of  more  or  less  (generally  less)  intelligence, 
and  with  no  other  than  picked-up  knowledge.  The 
trained  nurse  is  now  considered  to  be  of  so  much 
importance  in  the  sick-room  that  it  is  astonishing 
that  the  medical  profession  and  the  public  were 
content  to  wait  so  long  for  her.  So  important  is 
she,  that  it  may  be  safely  said  that  in  many  cases, 
particularly  in  typhoid  fever  and  such  wasting 
diseases,  she  really  does  as  much,  if  not  more,  good 
than  the  physician.  This,  of  course,  is  true  only  of 
the  good  nurse,  the  careful  nurse,  the  clean  nurse. 

9 


HYGIENE   OF   THE  SICK-ROOM. 


A  nurse  has  power,  too,  to  do  much  harm. 
Instead  of  preventing  disease,  as  is  her  duty,  she 
may  carry  it.  She  may  be  the  means  of  unwit- 
tingly spreading  contagion,  when  by  a  little  pre- 
caution this  could  be  avoided.  To  this  end  such 
a  nurse  should  study  the  subject  of  preventive 
medicine,  and  know  the  reason  why  she  does 
certain  things.  When  Pope  said, "  A  little  learning 
is  a  dangerous  thing,"  it  is  not  clear  what  he  ex- 
actly meant.  In  the  present  time  such  a  statement 
would  have  to  be  modified.  If  this  be  taken  in  its 
literal  sense,  then  many  a  physician,  aye,  many  a 
man,  carries  a  dangerous  weapon  in  that  "  little 
learning." 

While  it  may  not  be  necessary  for  a  nurse  to 
take  a  practical  course  in  "bacteriology,  yet  she. 
should  have  a  good  idea  of  the  causes  of  contagion, 
the  modes  of  infection,  and  understand  some  of 
the  practical  results  of  the  laboratory.  To  this 
end  this  little  book  is  offered  to  the  nursing  pro- 
fession, with  the  hope  that  it  may  spread  some 
clearer  ideas  on  those  invisible  foes,  the  bacteria. 


CHAPTER  I. 

BACTERIOLOGY. 

It  has  often  been  asked  what  bacteria  are  and 
where  they  come  from.  These  are  questions  which 
cannot  be  answered  in  a  few  words.  That  disease 
is  never  absent  from  a  large  community,  or  collec- 
tion of  people,  is  well  known  to  all.  Now  the  cause 
of  the  spread  of  disease  was  explained  by  attribu- 
ting it  to  a  materies  morbi,  but  this  expression  was 
not  explained. 

But  as  we  accumulate  and  compare  experience, 
we  believe  more  and  more  that  all  infectious  dis- 
eases are  caused  by  certain  minute  germs  or  micro- 
organisms, of  which  the  most  important  forms 
belong  to  the  bacteria,  and  that  each  disease  has  its 
own  particular  organism,  which  always  causes  this 
disease  in  the  person  or  animal  susceptible  to  it, 
and  never  by  any  chance  causes  another  disease. 
Now  if  these  disease  germs  are  not  everywhere,  they 
are  so  generally  present  that  it  is  often  a  wonder  that 
disease  is  not  more  prevalent  than  it  actually  is. 

1 1 


12  HYGIENE   OF   THE  SICK-ROOM. 


Knowing,  as  we  do,  the  value  of  prevention,  it  is 
our  duty  as  far  as  possible  to  try  to  keep  these  in- 
visible foes  from  attacking  the  weaker  members  of 
humanity,  and  this  the  nurse  has  in  her  power  to  do 
as  much  as  the  physician,  if  not  more  so.  To  un- 
derstand these  micro-organisms  is  no  small  under- 
taking. Indeed,  investigators  in  many  parts  of  the 
world  are  devoting  their  whole  life  to  the  study  and 
classification  of  these  organisms,  and  yet  they  are 
far  from  comprehending  the  whole  subject.  There- 
fore it  may  seem  almost  futile  to  attempt  to  set 
forth  in  a  clear  manner  just  what  these  bacteria  are 
and  what  bacteriology  is. 

These  pathogenic  or  disease-producing  germs 
may  exist  in  the  healthy  body  without  necessarily 
giving  rise  to  disease.  In  spite  of  the  accumula- 
tion of  new  drugs  and  drug  preparations,  most 
thinking  physicians  admit  that  many  diseases  when 
once  started  cannot  be  shortened  in  their  course  by 
medication,  even  if  some  of  the  worst  symptoms 
can  be  mitigated.  Recognizing  the  fact  that  pre- 
vention is  better  than  cure,  the  attempt  has  been 
made  to  cut  short  the  spread  of  certain  so-called 
preventable  diseases  by  proper  hygienic  care.  To 


BACTERIOLOGY.  13 

do  this  is  largely  the  province  of  the  trained  and 
skilled  nurse,  under  the  guidance  of  the  physician. 
The  same  thing  may  be  accomplished  to  a  less 
degree  by  the  intelligent  mother,  or  by  some  other 
adult  member  of  the  family.  To  this  end  it  should 
be  impressed  on  every  nurse,  be  she  trained  or  not, 
that  cleanliness  is  the  essential  to  success  in  every 
case,  whether  in  a  surgical  operation  or  in  prevent- 
ing the  spread  of  certain  diseases.  She  should 
also  remember  that  hygienic  cleanliness  means 
much  more  than  aesthetic  cleanliness,  the  two 
being  by  no  means  identical.  The  scientific  basis 
of  preventive  medicine  must  be  the  accurate  know- 
ledge of  the  causative  agents  of  these  diseases, 
and  this  is  the  study  of  bacteriology. 

Bacteriology,  as  we  now  understand  it,  is  the 
study  of  those  minute  organisms  called  bacteria, 
their  appearance,  shape,  manner  of  growth  and 
existence,  and  their  effects  on  animals  and  human 
beings.  This  is  in  part  what  bacteriology  means. 
The  little  organisms  are  called  bacteria  (little 
staves),  bacilli  (little  rods),  micrococci  (little 
spheres).  The  rods  and  staves  are  of  different 
lengths  and  thicknesses,  and  the  spheres  are  like 


14  HYGIENE   OF   THE  SICK-ROOM. 

small  billiard  balls,  and  are  sometimes  spherical 
and  sometimes  oval ;  they  may  exist  in  pairs  or 
chains.  Although  bacteriology  has  only  been 
recognized  as  a  part  of  medical  science  for  about 
ten  to  fifteen  years,  still,  the  foundation  of  this 
subject  was  laid  by  botanists  many  years  ago,  and, 
indeed,  some  have  thought  it  was  only  a  more 
refined  part  of  botany.  It  seems  wonderful  that 
such  a  science,  and  an  important  one,  too,  could 
have  originated  and  could  have  created  such  revo- 
lutions in  our  ideas  of  the  origin  of  disease  as 
bacteriology  has  done.  Strictly  speaking,  how- 
ever, bacteriology  had  its  beginning  more  than 
two  hundred  years  ago,  with  certain  observations 
made  by  a  Dutchman  (not  a  German,  but  a  native 
of  Holland)  named  Leeuwenhoek,  who  made  the 
first  discoveries  in  1675.  At  this  early  date 
Leeuwenhoek,  with  the  aid  of  a  crude  and  imper- 
fect microscope,  endeavored  to  study  these  organ- 
isms, and  tried  to  find  out  where  they  came  from 
and  what  their  connection  was  with  certain  epi- 
demic diseases.  Still  later,  Will,  in  1752,  endeav- 
ored to  classify  the  then  known  bacteria,  but  his 
work  amounted  to  little.  In  1773-1786  Otto 


BACTERIOLOGY.  15 


Friedrich  Muller  gave  some  of  these  organisms 
names  which  we  have  not  yet  found  it  necessary 
to  change.  Thus  we  see  that  these  few  great 
minds,  evidently  far  in  advance  of  their  time, 
and  probably  looked  upon  by  their  contempo- 
raries as  eccentrics,  had  done  such  good  work 
that  a  part  of  it  still  stands,  like  the  old  Roman 
aqueducts,  not  to  be  improved  upon  at  the  pres- 
ent time. 

One  theory  as  to  the  existence  of  these  bac- 
teria was  that  of  "  spontaneous  generation."  All 
these  investigators  believed  in  the  spontaneous 
growth  of  these  substances,  that  they  sprang  into 
existence  without  parents,  so  to  speak,  just  as 
we  may  see  the  growth  or  mould  on  the  tops  of 
the  jelly  glasses  in  the  pantry  ;  it  seems  to  have 
come  from  nothing.  Now  we  believe,  in  this 
connection,  that  out  of  nothing,  nothing  can  come, 
and  that  where  bacteria  are  found,  we  may  infer 
that  they  came  from  other  bacteria  before  them. 
It  was  also  thought  that  they  sprang  into  exist- 
ence from  inorganic  matter,  and  the  question 
was,  "  Did  they  belong  to  the  animal  or  vege- 
table kingdom  ?  " — a  problem  which  it  has  been 


1 6  HYGIENE   OF   THE  SICK-ROOM. 

difficult  for  many  to  solve.  They  lie  so  close  to 
the  borderland  between  animal  and  vegetable 
bodies,  and  possess  so  many  characteristics  of 
both,  that  proofs  for  either  kingdom  may  be 
brought  up,  but  they  are  generally  classed  with 
the  vegetable.  Their  classification  is  very  diffi- 
cult ;  some  are  studied  according  to  their  shape, 
behavior  under  different  circumstances — to  be 
noted  later — manner  of  growth  on  culture  media, 
effects  on  animals,  etc. 

The  two  bacteriologists  who  are  best  known 
to  the  public  at  large,  and  who  have  probably 
done  most  for  this  department  of  medicine,  are 
Pasteur  and  Koch.  Pasteur's  work  was  earlier 
and  was  on  such  subjects  as  the  micro-organisms 
of  fermentation,  and  this  was  applied  practically 
to  the  making  of  yeast  for  purposes  of  fer- 
mentation. Then  his  work  on  the  diseases  affect- 
ing silk-worms,  sheep,  and  chickens,  and  more 
recently  his  researches  in  hydrophobia,  have  not 
only  been  a  valuable  contribution  to  science,  but 
have  been  of  incalculable  value  in  saving  many 
lives  and  large  sums  of  money.  Koch,  the 
German  bacteriologist,  is  no  less  famous,  if  his 


BA  CTERIOLOG  Y.  \  7 


work  may  not  have  yielded  such  practical  results 
as  Pasteur's.  Koch's  principal  work  is  on  the 
wound  infection  diseases,  anthrax,  tuberculosis, 
and  Asiatic  cholera. 

In  regard  to  these  simple  organisms  them- 
selves, it  is  very  hard  to  give  any  conception 
of  their  size,  but  this  may  in  a  measure  be  done 
by  comparison  with  objects  whose  size  is  already 
known.  It  will  also  be  just  as  difficult  to  under- 
stand how  it  is  possible  to  handle  these  little 
bodies,  'and  to  study  them  as  we  are  able  to  do 
and  learn  their  life  history.  Most  of  these 
organisms  are  rod-shaped,  and  an  ingenious 
writer  has  said  that  fifteen  hundred  of  the 
best  known  bacteria  placed  end  to  end  would 
just  reach  across  the  head  of  a  pin.  This 
gives  a  much  better  idea  of  their  size  than  if 
given  in  fractions  of  an  inch  or  a  millimeter. 
Their  manner  of  growth  varies ;  some  grow  out 
to  great  length  and  divide  by  constriction,  others 
are  formed  from  a  central  spot  or  spore  within 
the  rod.  The  rod  opens  and  the  seed  or  spore 
falls  out  and  propagates  its  kind.  In  some  forms 
they  grow  out  to  long  chains  before  dividing. 


1 8  HYGIENE   OF  THE  SICK-ROOM. 


The  growth  of  these  micro-organisms  under  or- 
dinary circumstances  is  so  rapid  that  a  single 
germ  may  give  rise  to  an  incredible  number  in 
a  short  time ;  indeed,  a  writer  has  calculated  that 
a  single  germ  may  give  birth  to  sixteen  and  a  half 
million  germs  in  twenty-four  hours  ;  or,  to  make 
it  more  startling,  a  single  bacillus  the  one  one- 
thousandth  of  an  inch  in  length,  if  allowed  to  in- 
crease without  restriction,  could  in  less  than  five 
days  give  rise  to  enough  germs  to  fill  as  much 
space  as  is  occupied  by  all  the  oceans"  on  the 
earth's  surface,  supposing  them  to  have  an  aver- 
age depth  of  one  mile.  There  need  be  no  fear, 
however,  for  all  these  organisms  are  not  harmful. 
On  the  contrary,  many  do  good,  as  will  be  shown 
later ;  of  those  that  are  harmful  many  die,  and  on 
the  principle  of  the  survival  of  the  fittest,  not  all 
bacteria  that  survive  are  pathogenic  or  disease- 
producing. 

It  is  only  necessary  to  look  around  us  to  notice 
of  what  benefit  some  of  these  micro-organisms  are. 
Their  presence,  for  instance,  is  one  of  the  causes 
of  fermentation,  and  they  are  cultivated  for  this 
purpose  to  be  used  in  making  beer,  and  they  also 


BACTERIOLOGY.  19 


give  that  peculiar  odor  and  flavor  to  old  cheese 
so  dear  to  Epicureans.  Another  way  in  which 
these  organisms  do  good  is  by  splitting  up  the 
nitrogenous  bodies  and  hastening  decomposition. 
All  refuse  animal  or  vegetable  matter  thrown  out 
or  exposed  to  what  we  call  decomposition  disap- 
pears in  time,  and  this  disappearance  is  due  to  the 
activity  of  certain  minute  organisms  which  feed 
upon  these  substances  and  reduce  them  to  their 
ultimate  parts.  Some  organisms  only  live  on 
living  bodies,  others  on  dead  bodies,  and  some  on 
both.  They  have  many  peculiarities ;  some  cause 
that  peculiar  phosphorescence  which  we  see  on 
the  water  at  times.  Their  manner  of  growth,  too, 
is  very  peculiar;  some  are  so  hostile  that  they 
cannot  live  in  each  other's  presence ;  others, 
again,  are  so  affectionate  that,  like  Damon  and 
Pythias,  they  cannot  live  apart. 

Thus  we  see  that  these  bacteria  make  known 
their  presence  in  various  ways.  To  say  that  they 
are  everywhere  would  be  exaggerating  the  truth, 
but  that  they  are  very  prevalent  is  without  doubt. 
They  are  particularly  prevalent  in  crowded  com- 
munities, in  cities,  and  in  enclosed  places  where 


HYGIENE   OF  THE  SICK-ROOM. 


many  people  come  together ;  this  is  especially 
true  in  hospitals.  Such  bodies  have  a  tendency 
to  settle  to  the  ground,  so  that  the  air  in  a  closed 
room  is  comparatively  free  from  these  impurities, 
but  in  a  room  in  which  there  is  motion  and  the 
air  is  disturbed  by  walking,  the  dust  thus  driven 
about  by  currents  of  air  contains  numbers  of  these 
organisms.  It  is  only  necessary  to  notice  a  sun- 
beam slanting  across  the  room  in  which  there  is 
much  dust  to  prove  this  statement.  Again,  such 
organisms  are  less  abundant  when  the  ground 
surface  is  moist,  so  that  the  germs  adhere  and 
have  no  tendency  to  fly  about.  If,  then,  disease 
is  so  prevalent  in  the  form  of  these  minute  or- 
ganisms in  the  air,  it  seems  wonderful,  indeed, 
that  so  many  escape,  but  that  there  are  good 
reasons  why  so  many  escape  will  be  shown  later. 
The  methods  of  study  of  these  organisms  are 
threefold — by  the  microscope,  by  cultivation,  and 
by  inoculation  into  animals.  As  seen  under  the 
microscope,  these  bacteria  usually  have  no  color, 
therefore  we  have  to  make  use  of  certain  artificial 
stains  to  make  them  visible,  and  even  then  we  must 
use  lenses  which  magnify  from  five  hundred  to 


BA  CTERIOL  OGY.  21 


fifteen  hundred  times.  The  staining  fluids  which 
we  usually  employ  are  the  aniline  colors,  products 
of  coal  tar.  They  are  fuchsine  or  red,  violet,  blue, 
and  brown.  The  principle  of  staining  depends 
upon  the  fact  that  most  bacteria  hold  the  stain 
much  faster  than  other  substances  on  the  slide. 
For  instance,  in  staining  a  preparation,  the  color- 
ing fluid  is  poured  on  and  every  part  is  stained 
homogeneously ;  then,  recognizing  the  fact  experi- 
ence has  taught  us,  that  bacteria  have  a  greater 
affinity  for  these  coloring  fluids  than  for  any  other 
substances,  the  preparation  is  decolorized.  This  is 
usually  done  with  some  weak  acid.  Thus,  suppose 
the  preparation  has  been  stained  with  fuchsine;  it 
is  dipped  into  a  weak  solution  of  muriatic  acid, 
which  washes  out  the  color,  and  as  the  bacteria 
hold  on  to  the  color  more  closely  than  the  other 
tissues,  a  point  is  reached  which  repeated  experi- 
ments have  shown  to  be  right  where  the  bacteria 
are  stained  and  all  else  is  unstained.  By  using 
these  stains  in  this  way,  which  it  is  hardly  neces- 
sary to  describe  more  fully,  we  are  enabled  to 
study  the  shape  of  these  little  bodies  with  exact- 
ness. 


HYGIENE   OF   THE  SICK-ROOM. 


Naturally,  the  process  of  coloring  deprives  them 
of  life,  on  account  of  the  immersions  into  alcohol 
and  acids ;  therefore  if  it  be  desired  to  study  these 
organisms  in  motion  (that  is,  those  that  have  inde- 
pendent motion),  it  must  be  done  in  an  uncolored 
condition,  which  is  very  difficult.  As  so  many  of 
these  organisms  have  nearly  the  same  shape  and 
size  and  general  appearance,  we  must  resort  to 
other  additional  means  to  differentiate  and  classify 
them.  This  we  do  by  cultivating  them  in  suitable 
media.  The  culture  media  most  frequently  used 
are  made  of  bouillon,  gelatine,  and  agar-agar. 
Constant  study  by  professional  bacteriologists  has 
shown  that  some  bacteria  grow  better  on  one 
medium  and  others  better  on  another.  In  looking 
at  the  two  solid  media,  gelatine  and  agar-agar, 
we  notice  first  whether  in  its  growth  the  or- 
ganism cultivated  liquefies  the  medium  or  not, 
or  whether  it  grows  as  a  filmy  gauze  on  the  sur- 
face of  the  medium,  or  whether  it  produces  a 
growth  of  coloring  substance  on  the  surface. 
The  way  we  separate  one  kind  of  organism  from 
another,  in  a  mixture  containing  several  different 
kinds,  is  by  the  very  ingenious  plate  method  first 


BA  CTERIOL  OGY.  23 

suggested  by  Koch.  If  we  have  a  handful  of 
various  kinds  of  seeds,  such  as  grass,  hay,  rye, 
barley,  etc.,  and  are  not  able  to  separate  them  by 
looking  at  them,  it  is  possible  to  resort  to  the 
method  of  strewing  them  on  a  piece  of  ground,  and 
when  they  grow  each  particular  kind  may  be  sep- 
arated from  the  others.  Now  in  the  same  way 
bacteriologists  separate  a  large  number  of  bacteria 
in  the  same  mixture.  For  instance,  a  little  of  a 
mixture  containing  several  different  kinds  of  bac- 
teria is  put  into  a  test  tube  containing  sterilized 
and  liquefied  agar-agar,  which  is  then  poured  upon 
a  glass  plate  which  has  been  thoroughly  sterilized. 
This  is  carefully  covered  to  keep  micro-organisms 
from  falling  on  it,  and  it  is  put  into  the  thermostat 
or  brood-oven,  that  is,  a  small  cupboard  in  which 
the  temperature  is  automatically  always  kept  at 
Q8f  °  F.,  body  heat.  The  bacteria  which  are  in  the 
agar-agar  are  thus  scattered  over  this  entire  sur- 
face, and  after  twenty-four  hours  in  the  thermostat, 
on  looking  at  the  plate,  we  see  scattered  here  and 
there  different  kinds  of  growths  or  colonies,  as 
they  are  called.  By  carefully  studying  these  dif- 
ferent colonies,  and  taking  a  little  bit  from  each  one 


24  HYGIENE   OF  THE  SICK-ROOM. 


and  putting  it  on  a  cover  glass  and  staining  it  in 
the  manner  above  described,  we  are  able  much 
more  exactly  to  distinguish  the  various  kinds,  and 
by  putting  the  plate  under  a  low  power  of  the  mi- 
croscope we  may  study  the  shape  of  each  colony 
and  its  manner  of  growth.  In  these  two  ways,  by 
repeated  study  we  are  able  to  distinguish  and  clas- 
sify a  large  number  of  the  bacteria. 

The  third  method,  that  of  inoculation,  is  abso- 
lutely necessary  in  order  to  prove  that  a  certain 
organism  is  the  cause  of  a  certain  disease ;  for  ex- 
ample, two  different  bacteria  may  have  the  same 
appearance  microscopically,  and  the  same  pecu- 
liarities of  growth  on  the  media,  and  yet  when  in- 
oculated under  the  skin  of  a  susceptible  animal 
produce  entirely  different  results.  Before  we  can 
be  sure  that  a  given  organism  is  the  cause  of  a 
given  disease,  we  must  be  able  to  take  it  from  the 
diseased  animal  or  man,  assure  ourselves  of  its 
^hape,  size,  appearance,  and  manner  of  growth, 
and  reproduce  the  same  disease  from  its  inocula- 
tion into  the  same  kind  of  animal.  This  has  been 
done  in  comparatively  few  diseases.  Those  dis- 
eases in  which  we  are  certain  of  the  specific  or- 


HA  CTERIOL  OGY.  25 

ganisms  are  tuberculosis,  Asiatic  cholera,  typhoid 
fever,  erysipelas,  relapsing  fever,  glanders,  leprosy, 
malaria,  and  a  few  others. 

The  bacteria  of  most  diseases  are  generally 
rather  easily  destroyed  by  heat,  by  certain  anti- 
septics, and  some  by  prolonged  drying  and  by 
freezing,  but  their  spores  possess  great  powers  of 
endurance  and  are  very  resistant.  For  instance, 
while  bacteria  cannot  grow  in  ice,  their  spores, 
and  even  they  themselves,  remain  viable,  and  when 
brought  into  the  proper  conditions  can  cause  the 
growth  of  fresh  bacteria ;  thus  we  believe  that  in- 
fected water  may  freeze  and  form  ice  containing  a 
large  number  of  bacteria,  whose  power  to  do  harm 
is  held  in  abeyance ;  but  let  that  ice  once  be 
brought  into  use,  and  it  can  spread  such  a  disease 
as  typhoid  fever. 

There  are  other  forms  of  minute  organisms  capa- 
ble of  causing  infectious  diseases  besides  the  bacteria. 
The  parasite  causing  malaria,  for  instance,  is  not  one 
of  the  bacteria,  but  belongs  probably  to  the  sporo- 
zoa,  a  low  form  of  animal  life.  A  form  of  dys- 
entery is  caused  by  an  amoeba.  It  is  possible 
3 


26  HYGIENE   OF  THE  SICK-ROOM. 

that  many  of  the  contagious  diseases  the  specific 
causes  of  which  have  not  yet  been  discovered  are 
produced  by  parasitic  organisms  which  are  not 
bacteria.  We  are,  however,  most  familiar  with  the 
life  history  and  properties  of  the  bacteria. 


CHAPTER  II. 

INFECTION  AND  DISINFECTION. 

In  setting  out  on  a  new  subject  there  necessa- 
rily arise  certain  expressions,  some  technical,  others 
of  more  general  use,  whose  exact  definition  is  not 
very  clear,  and  yet  which  the  student  should  try 
to  understand  at  the  start.  The  question  is  often 
asked,  "  What  is  the  difference  between  contagious 
and  infectious  ? "  This  question  is  more  easily 
asked  than  answered.  In  reality,  the  two  words 
have  not  kept  up  with  the  onward  march  of  medi- 
cal science,  and  the  difficulty  of  a  distinction  is  only 
too  apparent  to  those  who  will  take  the  trouble  to 
consult  the  best  authorities.  Contagious  means  in- 
fection by  contact,  whether  mediate  or  immediate, 
while  infectious  means  a  condition  produced  by 
any  poison  from  without.  Infectious  is  a  broader 
term  and  includes  contagious.  Whatever  is  con- 
tagious is  infectious,  but  not  all  that  is  infectious 
is  contagious.  Infection  has  also  been  defined  as 
the  condition  produced  by  the  entrance  and  multi- 

27 


28  HYGIENE   OF  THE  SICK-ROOM. 

plication  of  pathogenic  or  disease-producing  micro- 
organisms within  the  body. 

When  the  material  from  a  diseased  person  is  in- 
serted into  the  body  of  a  healthy  person  and  the 
disease  is  reproduced  it  is  called  inoculable.  Some 
diseases  are  inoculable  which  are  not  infectious, 
and  the  reverse  is  true.  The  word  communicable 
may  be  used  to  cover  all  these  ways  of  conveying 
disease.  When  we  say  that  a  disease  is  infective, 
we  mean  that  it  infects  or  affects  the  whole  body 
as  distinguished  from  those  diseases  which  affect  a 
part  of  the  body  only.  Most  contagious  diseases 
are  infective,  but  when  a  disease  such  as  ring- 
worm can  be  inoculated  into  different  parts  of  the 
body  at  once,  this  is  an  exception.  In  this  way 
we  test  sometimes  whether  a  disease  has  become 
general  or  is  only  local ;  for  when  infective,  no 
local  manifestations  will  appear  on  inoculation. 

When  a  person  is  inoculated  with  a  disease  there 
is  evidently  a  poison  introduced  into  the  system — 
a  poison  which  grows  and  reproduces  itself  in  the 
body  almost  indefinitely.  This  poison  is  living. 
This  is  very  different  from  the  poisoning  caused  by 
a  mineral  or  inorganic  substance,  which  may  cause 


INFECTION  AND   DISINFECTION.  29 


death  but  never  increases  in  amount  in  the  body. 
In  all  these  diseases  there  is  an  attempt  on  the  part 
of  nature  to  get  rid  of  the  poison.  This  is  done 
through  the  skin,  the  intestinal  tract,  etc. 

The  malarial  diseases,  Asiatic  cholera  and  typhoid 
fever,  represent  the  miasmatic-contagious  diseases 
which  are^  caused  by  a  specific  poison  usually  exist- 
ing outside  of  the  body  and  received  into  it  from 
time  to  time.  Such  diseases  are  not  supposed  to 
be  communicable  from  one  individual  to  another. 
The  eruptive  diseases  pass  from  one  person  to 
another  and  are  more  strictly  contagious. 

Thus  the  two  words,  contagious  and  infectious, 
are  used  rather  loosely,  and  one  can  hardly  be 
blamed  for  this  when  the  advances  in  this  branch 
of  medicine  are  considered,  while  these  two  words 
have  existed  on,  not  keeping  up  with  the  times. 

Diseases  that  occur  in  certain  localities  in  sudden 
and  violent  outbreaks,  affecting  a  large  number  in 
proportion  to  the  population,  are  called  epidemic ; 
while  those  diseases  which  prevail  in  a  given  place 
are  called  endemic ;  and  those  which  have  a  ten- 
dency to  spread  rapidly  are  called  pandemic.  These 
diseases  do  not  appear  as  soon  as  the  system  is  ex- 


30  HYGIENE   OF   THE  SICK-ROOM. 


posed  to  them,  but  take  a  certain  time  to  develop. 
This  is  called  the  stage  of  incubation,  and  varies  in 
different  diseases.  The  following  is  a  list  of  the 
principal  diseases  with  their  periods  of  incuba- 
tion : — 

Measles, 10          days 

Scarlet  fever, 4  to     7-" 

Small-pox, 9  to  16  " 

Varioloid, 9  to  16  " 

Chicken-pox,    .........       2  to    4  " 

Typhoid  fever, 7  to  21  " 

Typhus  fever, 2  to  21  " 

Relapsing  fever, 5  to    7  " 

Malaria  (intermittent  fever),  .     .    .      7  to  21  " 

Erysipelas I  to    3  " 

Diphtheria,  . " 3  " 

Mumps, 18  " 

These  periods  of  incubation  may  vary  accord- 
ing to  circumstances.  They  are  especially  vari- 
able when  attempts  have  been  made  to  prevent 
the  disease  by  disinfection. 

In  attempting  to  check  the  spread  of  these 
infectious  diseases,  we  have  always  the  fact  that 
they  are  caused  by  some  materies  morbi  or  mor- 
bid matter,  and  experience  shows  that  certain 
substances  are  of  great  use  in  the  sick-room  and 


INFECTION  AND   DISINFECTION.  31 

elsewhere  in  preventing  the  further  spread  of 
disease,  and  in  destroying  the  disease  poison  as 
soon  as  it  has  left  the  body  of  the  patient.  The 
various  substances  used  are  called  antiseptics, 
disinfectants,  and  deodorants.  Unfortunately,  these 
terms  have  been  so  much  confused  that  not  only 
the  non-medical  public,  but  even  many  of  the 
medical  profession,  do  not  know  the  difference,  or, 
if  they  do  know,  misapply  these  terms  to  the 
confusion  of  others.  An  antiseptic  is  that  which 
retards,  prevents,  or  arrests  putrefaction,  decay,  or 
fermentation,  or  the  bacteria  which  cause  these  ; 
while  a  disinfectant  is  that  which  entirely  destroys 
the  poison  and  the  germs  which  cause  it.  A 
deodorant  is  simply  that  which  removes  or 
deadens  unpleasant  smells.  A  substance  may  be 
malodorous  and  yet  be  harmless,  and  one  may  be 
free  from  odor  and  be  teeming  with  dangerous 
germ  life. 

It  might  be  unpleasant  to  some  nurses  if  told 
that  they  must  keep  clean  in  their  vocation.  If 
told  that  cleanliness  meant  "  freedom  from  dirt, 
filth,  or  any  foul  matter,"  as  the  dictionary  defines 
it,  it  would  sound  very  harsh  indeed,  for  one's 


32  HYGIENE   OF  THE  SICK-ROOM. 


first  idea  of  a  modern  hospital  nurse  is  a  woman 
above  all  things  neat,  tidy,  and  clean.  It  is  not 
so  much  the  presence  of  actual  dirt  visible  to 
the  naked  eye  that  does  harm,  but  that  minute 
microscopical  dust  to  which  disease-producing 
germs  are  attached.  Against  such  substances 
does  the  nurse  have  to  guard,  and  to  the  presence 
and  action  of  such  minute  bodies  are  due  many 
of  the  diseases  which  are  never  absent  from  a 
large  hospital  or  community. 

The  principal  modes  of  infection  are  by  the 
air,  water,  and  food.  The  number  of  bacteria  in 
the  air  varies  greatly  according  to  certain  con- 
ditions. On  high  mountains  and  far  out  at  sea 
the  air  is  generally  free  from  bacteria;  the 
nearer  we  approach  civilization  the  more  abun- 
dant are  the  bacteria  in  the  air.  Indeed,  many 
of  the  diseases  are  introduced  into  the  system 
through  the  mouth  and  breathing  apparatus, 
and  the  organisms  of  wound  infection  usually 
gain  access  to  the  body  by  the  air.  The  latter 
are  particularly  abundant  in  the  air  of  infected 
regions,  such  as  in  hospitals,  etc.  The  organ- 
ism of  malaria,  as  is  well  known,  can  be  carried 


INFECTION  AND   DISINFECTION.  33 


by  the  air  to  great  distances  and  cause  the 
disease  in  regions  where  one  would  not  expect 
to  find  it.  This  may  be  readily  believed  when 
we  know  that  sand  and  dust  may  be  lifted  by 
the  wind  and  carried  incredible  distances.  Thus 
sand  and  dust  from  the  great  African  desert 
have  been  found  in  sand  showers  in  Berlin, 
and  sand  showers  have  also  occurred  on  ships 
six  hundred  to  eight  hundred  miles  from  land. 
Such  showers  have  also  been  described  in  the 
western  part  of  the  United  States.  In  enclosed 
places,  and  especially  in  hospitals,  the  air,  ren- 
dered impure  by  the  exhalations  of  the  sick, 
may  contain  almost  any  kind  of  organism  in 
addition  to  the  unhealthy  excretions  from  the 
body,  which  when  dried  may  be  carried  about 
the  room. 

The  soil  or  ground  contains  a  large  number 
of  organisms  which  by  gravitation  find  their 
way  to  the  ground  very  easily.  The  bacilli  of 
typhoid  fever  or  Asiatic  cholera — germs  of  the 
greatest  interest  to  mankind — may  be  found  in 
some  soils,  and  the  bacillus  of  tuberculosis  is 
also  at  times  found  in  the  ground,  while  certain 


34  HYGIENE   OF   THE  SICK-ROOM. 


kinds  of  earths  seem  constantly  to  contain  the 
organism  of  tetanus.  These  organisms,  however, 
are  usually  only  on  the  surface,  and  a  few  feet 
below  the  surface  there  are  absolutely  no  germs 
to  be  found.  While  the  soil  may  keep  certain 
organisms  viable  for  a  longer  or  shorter  time, 
it  is,  fortunately,  not  a  good  breeding  place  for 
them.  This  is  particularly  noted  in  cemeteries. 
Bodies  of  persons  dying  from  the  more  common 
infectious  diseases  might  be  supposed  to  spread 
the  disease,  but  this  is  not  so,  for  the  antag- 
onism between  the  germs  of  decomposition  and 
the  germs  of  the  infectious  diseases  causes  a 
gradual  destruction,  of  both  and  a  lessening  of 
the  spread  of  disease.  Hence  one  rarely  or 
never  hears  of  authenticated  accounts  of  the 
spread  of  disease  from  a  cemetery.  Of  course, 
such  varying  conditions  as  moisture,  porosity, 
quality  of  soil,  etc.,  may  vary  the  length  of 
life  of  germs  in  the  soil. 

Dr.  William  H.  Welch,  in  the  Medical  News, 
says  in  this  connection  that  "the  soil  is  not  a 
good  breeding-place  for  most  of  the  infectious 
bacteria  with  which  we  are  acquainted,  but 


INFECTION  AND  DISINFECTION,  35 


that  it  can  retain  for  a  long  time  with  unim- 
paired vitality  those  which  produce  spores  or 
which  offer  considerable  resistance  to  injurious 
agencies,  such  as  anthrax  bacilli,  tubercle  bacilli, 
and  the  pyogenic  cocci."  In  this  connection  the 
same  author  adds  : — "  Before  leaving  the  subject 
of  the  ground  as  a  source  of  infection,  permit 
me  to  indicate  briefly  some  conclusions  which 
may  be  drawn  from  what  has  been  said  as  to 
the  principles  which  should  guide  us  in  pre- 
venting infection,  directly  or  indirectly,  from  the 
ground. 

"  First  in  importance  is  to  keep  infectious  sub- 
stances as  far  as  possible  from  the  ground.  This 
implies  the  early  disinfection  or  destruction  of 
such  substances  as  typhoid  and  cholera  excreta 
and  tuberculous  sputum. 

"  Second.  The  ground  should  be  rendered  as  far 
as  practicable  unsuitable  for  the  continued  exist- 
ence of  infectious  germs.  This,  at  least  for  some 
diseases,  is  accomplished  by  a  proper  system  of 
drainage,  which,  moreover,  for  other  reasons, 
possesses  hygienic  importance. 

"  Third.     Means  should  be  provided  to  prevent 


36  HYGIENE   OF  THE  SICK-ROOM. 


waste  products  from  getting  into  the  ground 
around  human  habitations,  or  from  gaining  access 
to  water  used  for  drinking  or  domestic  purposes. 
In  cities  this  can  be  accomplished  only  by  a 
properly  constructed  system  of  sewers.  The 
system  of  storing  waste  products  in  cess-pools, 
whence  they  are  to  be  occasionally  removed, 
cannot  be  approved  on  hygienic  grounds.  There 
are  conditions  in  which  the  disposal  of  waste 
products  in  deep  wells  used  for  this  purpose,  and 
whence  these  products  can  filter  into  the  deep 
layers  of  the  ground,  may  be  permissible,  but 
this  can  never  be  considered  an  ideal  method  of 
getting  rid  of  excrementitious  substances,  and  is 
wholly  wrong  in  regions  where  wells  are  used  for 
drinking  water.  But  I  am  trespassing  with  these 
remarks  upon  a  province  which  does  not  belong 
to  me,  but  rather  to  practical  sanitarians  and  engi- 
neers. I  shall  add  that  the  advantage  gained  by 
preventing  organic  waste  from  soaking  into  the 
ground  is  not  so  much  that  the  ground  is  thereby 
rendered  better  adapted  to  the  existence  of  infec- 
tious micro-organisms,  but  is  due  rather  to  the  fact 
that  this  waste  is  likely  to  contain  infectious  germs. 


INFECTION  AND  DISINFECTION.  37 

"  Finally,  in  cities,  good  pavements,  absence  of 
unnecessary  disturbance  of  the  soil,  cleanliness 
of  the  streets,  and  laying  of  dust  by  sprinkling, 
are  not  only  conducive  to  comfort,  but  are  some- 
times hygienically  important  in  preventing  infec- 
tion from  the  ground  and  dust." 

Food  is  often  the  means  of  conveying  germs  into 
the  body.  Bacteria  in  the  air  may 'fall  on  the  food 
in  its  natural  condition,  as  on  fruit  and  uncooked 
food,  and  be  taken  into  the  stomach.  In  the  same 
way  flies  and  other  insects  may  step  in  contagious 
substances  and  deposit  some  of  this  on  food.  It 
is  not  impossible  that  such  vegetables  as  lettuce 
may  be  a  means  of  conveying  disease  poison  to 
the  body.  Such  vegetables  as  grow  near  the 
ground  and  are  eaten  uncooked  are  the  most 
favorable  conveyers  of  disease  germs.  It  is  very 
conceivable  that  a  farmer,  with  the  desire  to  raise 
as  large  and  productive  a  crop  of  lettuce  and 
other  such  vegetables  as  possible,  will  fertilize  his 
field  both  before  and  during  the  crop  with  faeces 
containing,  for  example,  typhoid  bacilli.  For- 
tunately, much  of  our  food  is  eaten  in  a  cooked 
condition,  and  the  high  temperature  necessary  for 


38  HYGIENE  OF  THE  SICK-ROOM, 

the  cooking  is  always  sufficient  to  destroy  noxious 
germs  and  their  spores. 

Water  may  become  a  constant  source  of  con- 
tamination, and  particularly  is  it  a  conveyer  of 
typhoid  fever  and  Asiatic  cholera,  not  only  when 
it  is  taken  into  the  body,  but  when  it  is  used  for 
the  purpose  of  cleansing  vessels  in  which  food  or 
milk  is  put  and  kept.  Ice,  another  form  of  water, 
is  by  no  means  an  uncommon  cause  of  typhoid 
fever.  *  Many  of  the  filters  in  daily  use  for  the 
purification  of  drinking  water  are  of  doubtful 
character.  Milk  is  a  very  dangerous  article  of 
diet  when  not  pure.  In  it  many  a  disease  germ 
may  grow  or  remain  alive  and  cause  such  diseases 
as  tuberculosis,  typhoid  fever,  etc.  Of  course, 
it  is  well  known  that  the  larger  parasites,  such  as 
the  tapeworm,  get  into  the  body  through  the 
food  and  drink.  Many  of  the  scrofulous  affec- 
tions in  children  are  undoubtedly  due  to  infec- 
tion from  milk  derived  from  tuberculous  cows. 

It  is  hard  to  understand  how  some  of  the  infec- 
tious diseases  are  hereditary.  An  inherited  defect 
in  the  tissues  causing  defective  vital  resistance 
may  be  the  cause  of  some  diseases.  This  pre- 


INFECTION  AND  DISINFECTION.  39 

disposition  passes  from  parent  to  child.  Also 
the  essential  cause  of  the  disease  may  be  trans- 
mitted from  mother  to  foetus.  This  has  been 
shown  in  erysipelas. 

Water  shown  by  chemical  tests  to  be  pure  may 
contain  typhoid  bacilli ;  on  the  other  hand,  the 
air  of  some  of  the  apparently  worst  sewers  has 
been  found  to  be  free  from  bacteria.  For  this 
reason  it  is  never  right  to  brand  an  article  of 
food  or  drink  as  pure  or  impure  until  it  has  been 
tested  both  chemically  and  bacteriologically.  To 
the  nurse  these  facts  may  not  be  of  so  much 
practical  use  as  of  scientific  interest,  but  the  in- 
telligent nurse  cannot  help  being  glad  to  know 
why  she  does  so  many  things  which  otherwise 
would  seem  to  her  useless.  These  dangers  from 
air,  water,  and  food  should  always  be  considered 
by  the  healthy,  and  much  more  so  by  the  sick, 
for  it  is  well  known  that  a  diseased  respiratory  or 
digestive  tract  is  much  more  susceptible  to  the 
attacks  of  disease  in  the  form  of  these  bacteria 
than  when  a  condition  of  health  exists.  Indeed, 
the  theory  that  fatigue  invites  disease  by  making 
the  powers  of  resistance  too  weak  can  readily  be 


40  HYGIENE   OF  THE  SICK-ROOM. 


accepted,  but  this  will  be  considered  in  another 
chapter. 

Disinfection  consists  in  making  harmless  all 
infective  material,  that  is,  in  destroying  all  dis- 
ease-producing germs.  It  is,  therefore,  the  fun- 
damental idea  in  preventing  infectious  diseases. 
The  ancients  and  those  of  more  modern  times 
used  fire  as  a  means  of  destroying  objects  infected 
by  disease,  and  later  on  certain  chemicals  were 
used  for  the  same  purpose,  but  this  was  done  in 
a  hap-hazard  way.  It  is  only  in  the  most  recent 
times,  since  bacteriology  has  shown  itself  to  be 
the  scientific  basis  of  all  disinfection,  that  the 
work  has  been  carried  on  in  a  thorough  manner. 
The  question  as  to  what  should  be  disinfected 
and  what  not,  is  answered  by  saying  that  every- 
thing containing  disease  germs  or  their  spores 
should  be  disinfected,  and  this  disinfection  is  not 
complete  until  all  the  bacteria  and  their  spores 
have  been  destroyed. 

The  three  methods  of  disinfecting  most  usually 
employed  are,  the  physical,  the  chemical,  and  the 
mechanical. 

Fire,  used  directly  on  such  objects  as  will  not 


INFECTION  AND   DISINFECTION.  41 


be  harmed  by  it,  is  the  best  disinfectant.  Expos- 
ing objects  to  moist  heat  for  a  sufficient  length 
of  time  will  thoroughly  destroy  all  bacteria  and 
their  spores.  Thus  tuberculous  sputum  is  ren- 
dered harmless  after  being  cooked  for  twenty 
minutes,  and  typhoid  bacilli  in  fifteen  minutes. 
All  substances  to  be  washed  should  first  be  boiled 
and  occasionally  stirred  to  insure  a  thorough 
disinfection  in  all  parts.  Dry  heat  was  used  for 
some  time  as  a  disinfectant,  but  it  failed  to  give 
satisfaction.  Many  germs  were  destroyed  by  it, 
but  the  spores  of  these  germs  seemed  to  with- 
stand the  dry  heat  for  a  long  time.  It  was  seen 
that  such  objects  as  pillows,  bed-covers,  etc., 
could  not  be  thoroughly  disinfected  in  this  way, 
as  the  dry  heat  could  not  penetrate  into  the 
centre,  and  this  part  was  often  many  degrees  lower 
than  the  outside.  Far  better  and  more  effective 
is  steam  heat  under  pressure,  which  penetrates 
much  more  rapidly  than  dry  heat,  and  disinfects 
much  more  thoroughly.  Cold  and  ventilation 
have  also  been  suggested  as  disinfectants.  Cold 
will  kill  some  bacteria,  but  in  general  has  no 
effect  on  their  spores.  Ventilation,  as  is  shown 


42  HYGIENE   OF   THE  SICK-ROOM. 

in  another  chapter,  dilutes   the  number  of  germs 
in  a  given  space,  but  does  not  destroy  them. 

Among  the  chemical  disinfectants,  corrosive 
sublimate  (i  :  1000)  has  until  very  lately  been 
looked  on  as  a  perfect  disinfectant.  Almost  all 
books  on  the  subject  recommend  it,  and  especially 
surgeons  use  it  for  the  disinfection  of  the  hands 
and  whatever  is  not  affected  by  its  chemical 
properties.  Recent  experiments  made  at  several 
laboratories,  and  especially  at  the  Johns  Hop- 
kins Pathological  Laboratory,  have  satisfactorily 
proved  that  corrosive  sublimate  is  a  less  reliable 
disinfectant  than  has  been  generally  supposed. 
This  statement  is  made  because  its  powers  of 
disinfection  have  for  so  long  been  accepted  with- 
out a  question  that  harm  has  doubtless  been  done 
by  an  undue  faith  without  sufficient  proof.  Pour- 
ing corrosive  sublimate  solution  into  spit  cups  was 
formerly  considered  as  sure  disinfection.  Now 
it  is  known  that  a  five  per  cent,  carbolic  acid 
solution  is  better,  and  boiling  out  the  cups  is  the 
best  thing  of  all.  Carbolic  acid  is  a  good  disin- 
fectant, because  it  does  not  hurt  the  metal  of  the 
instruments.  When  no  spores  are  present,  a  two 


INFECTION  AND  DISINFECTION.  43 


to  three  per  cent,  solution  of  carbolic  acid  will 
disinfect,  but  a  five  per  cent,  solution  is  necessary 
to  destroy  spores. 

An  excellent  disinfectant  is  the  oxide  of  cal- 
cium, or  quicklime.  Pfuhl,  in  the  "  Zeitschrift  fur 
Hygiene,"  Vol.  6,  gives  the  following  directions 
for  using  quicklime  in  disinfecting  faeces.  Slake 
calcined  lime  in  a  wooden  tub  or  vessel  with 
water,  using  about  60  parts  of  water  to  100  parts 
of  calcined  lime.  This  produces  calcium  hydrate 
in  powder.  Mix  this  powder  in  the  proportion 
of  about  one  part  to  four  parts  of  water.  This 
makes  milk  of  lime,  or  lime-water.  This  is  an 
excellent  disinfectant,  especially  for  faeces.  It 
should  be  thoroughly  mixed  with  typhoid  fever 
faeces  until  they  are  strongly  alkaline,  then  allowed 
to  stand  about  four  hours,  and  then  they  may  be 
thrown  out  without  danger.  The  important  point 
to  be  remembered  is  that  the  disinfectant  should 
be  thoroughly  mixed  with  the  suspected  faeces, 
and  then  allowed  to  stand  before  being  disposed 
of.  The  nurse  has  a  strong  temptation  to  add 
the  disinfectant  and  then  throw  out  the  faeces  at 
once. 


44  HYGIENE   OF   THE  SICK-ROOM. 


Crcolin  has  met  with  some  favor  as  a  lubricant 
and  disinfectant  in  making  digital  examinations 
of  the  vagina  and  uterus. 

The  trichloride  of  iodine,  aseptol,  chloride  of 
zinc,  the  diluted  mineral  acids,  and  certain  chemi- 
cal gases  have  all  more  or  less  powers  of  germ 
destruction.  In  using  sulphur,  as  is  emphasized 
elsewhere,  it  should  be  remembered  that  it  is  only 
effective  in  the  presence  of  moisture. 

Mechanical  disinfection  can  accomplish  much 
good.  Cleaning  with  brooms,  brushes,  wash- 
cloths, with  the  help  of  pumice  stone  and  sand, 
removes  mechanically  many  bacteria.  Esmarch 
has  advocated  the  rubbing  off  of  the  walls  and 
floor  of  an  infected  room  with  dry  bread  crumbs, 
taking  care  afterward  to  burn  the  bread.  It  is 
astonishing  how  many  bacteria  can  be  removed 
by  this  simple  method.  Of  course,  all  the  imple- 
ments used  in  cleaning  should  be  sterilized  or 
destroyed  by  burning.  This  method  of  cleaning 
should  not  take  the  place  of  the  first-mentioned 
ways,  but  should  precede  them. 

In  using  disinfection,  it  should  be  borne  in  mind 
that  that  method  which  is  the  most  thorough, 


INFECTION  AND  DISINFECTION.  45 


which  disinfects  the  object  most  quickly,  is  the 
one  to  be  preferred.  Again,  all  things  being  equal, 
the  simplest,  cheapest,  and  most  harmless  method 
of  disinfection  should  be  employed.  Lastly,  disin- 
fection should  be  carried  out  by  those  thoroughly 
skilled  in  the  work.  This  is  especially  necessary 
because  danger  of  spreading  a  disease  is  much 
greater  when  disinfection  is  badly  carried  out, 
rooms  and  objects  being  used  which  are  by  no 
means  free  from  danger.  Disinfection  is  practiced 
on  the  living,  the  dead,  on  products  of  secretion 
and  excretion,  on  rooms,  and  on  all  objects  which 
come  near  the  patient  and  on  all  food  which  is  sus- 
pected or  likely  to  be  dangerous.  The  diseases 
mentioned  are  the  principal  ones  against  which 
disinfection  is  practiced.  That  city  Health  Boards 
are  not  governed  by  the  most  recent  knowledge  is 
shown  by  the  fact  that  the  Health  Board  of  Balti- 
more requires  notification  of  such  a  disease  as 
mumps,  but  does  not  require  an  inspection  in  case 
of  typhoid  fever. 

In  the  report  of  the  Committee  on  Disinfectants 
appointed  by  the  American  Public  Health  Associa- 
tion, conclusions  were  drawn  as  to  the  most  useful 


46  HYGIENE   OF   THE  SICK-ROOM. 

agents  for  the  destruction  of  spore-containing  in- 
fectious material  as  follows  : — 

1.  Fire.     Complete  destruction  by  burning. 

2.  Steam  under  pressure.  105°  C.  (221°  F.)  for  ten 
minutes. 

3.  Boiling  in  water  for  half  an  hour. 

4.  Chloride  of  lime.*    A  four  per  cent,  solution. 

5.  Mercuric  chloride.     A  solution  of  i  :  500. 
For  the  destruction  of  infectious  material  which 

owes  its  infecting  power  to  the  presence  of  micro- 
organisms not  containing  spores,  the  Committee 
recommends : — 

1.  Fire.     Complete  destruction  by  burning. 

2.  Boiling  in  water  for  ten  minutes. 

3.  Dry  heat.     1 10°  C.  (230°  F.)  for  two  hours. 

4.  Chloride  of  lime.     A  two  per  cent,  solution. 

5.  Solution  of  chlorinated  soda.\    A  ten  per  cent, 
solution. 

6.  Mercuric  chloride.     A  solution  of  i  :  2000. 

7.  Carbolic  acid.     A  five  per  cent,  solution. 

8.  Stdphate  of  copper.     A  five  per  cent,  solution. 

*  Should  contain  at  least  twenty-five  per  cent,  of  available  chlo- 
rine. 

f  Should  contain  at  least  three  per  cent,  of  available  chlorine. 


INFECTION  AND   DISINFECTION.  47 

9.   Chloride  of  zinc.     A  ten  per  cent,  solution. 

10.  Sulphur  dioxide.*  Exposure  for  twelve  hours 
to  an  atmosphere  containing  at  least  four  volumes 
per  cent,  of  this  gas  in  presence  of  moisture. 

The  Committee  would  make  the  following  recom- 
mendations with  reference  to  the  practical  applica- 
tion of  these  agents  for  disinfecting  purposes  : — 


FOR  EXCRETA. 

(a)  In  the  sick-room  : — 

1.  Chloride  of  lime  in  solution,  four  per  cent. 
In  the  absence  of  spores  : — 

2.  Carbolic  acid  in  solution,  five  per  cent. 

3.  Sulphate  of  copper  in  solution,  five  per  cent. 
(^)  In  privy  vaults: — 

1.  Mercuric  chloride  in  solution,  I  :  500. f 

2.  Carbolic  acid  in  solution,  five  per  cent. 

(c)  For  the  disinfection  and  deodorization  of  the 


*  This  will  require  the  combustion  of  between  three  and  four  Ibs. 
of  sulphur  for  every  1000  cubic  feet  of  air  space. 

f  The  addition  of  an  equal  quantity  of  potassium  permanganate 
as  a  deodorant,  and  to  give  color  to  the  solution,  is  to  be  recom- 
mended. 


48  HYGIENE   OF  THE  SICK-ROOM. 


surface    of  masses    of  organic    material    in    privy 
vaults,  etc. : — 

Chloride  of  lime  in  powder. 

FOR    CLOTHING,    BEDDING,    ETC. 

(a)  Soiled  underclothing,  bed-linen,  etc. : — 

1.  Destruction  by  fire,  if  of  little  value. 

2.  Boiling  for  at  least  half  an  hour. 

3.  Immersion  in  a  solution  of  mercuric  chloride 
of  the  strength  of  I  :  2OOO  for  four  hours. 

4.  Immersion    in   a   two    per   cent,   solution    of 
carbolic  acid  for  four  hours, 

(b}  Outer  garments  of  wool  or  silk,  and  similar 
articles,  which  would  be  injured  by  immersion  in 
boiling  water  or  in  a  disinfecting  solution  : — 

1.  Exposure  in  a  suitable  apparatus  to  a  current 
of  steam  for  ten  minutes. 

2.  Exposure  to    dry  heat    at    a  temperature  of 
1 10°  C.  (230°  F.)  for  two  hours. 

(c]  Mattresses  and  blankets  soiled  by  the  dis- 
charges of  the  sick  : — 

1.  Destruction  by  fire. 

2.  Exposure   to    super-heated    steam,    105°    C. 
(221°  F.),  for  ten  minutes. 


INFECTION  AND   DISINFECTION.  49 


(Mattresses  to  have  the  cover  removed  or  freely 
opened.) 

3.  Immersion  in  boiling  water  for  half  an  hour. 

FURNITURE   AND    ARTICLES    OF  WOOD,   LEATHER,  AND 
PORCELAIN. 

Washing,  several  times  repeated,  with  : — 
Solution  of  carbolic  acid,  two  per  cent. 


i 


FOR   THE    PERSON. 

The  hands  and  general  surface  of  the  body  of 
attendants  of  the  sick  and  of  the  convalescents 
should  be  washed  with : — 

1.  Solution  of  chlorinated  soda  diluted  with  nine 
parts  of  water,  i  :  10 

2.  Carbolic  acid,  two  per  cent,  solution. 

3.  Mercuric  chloride,  i  :  1000. 

FOR    THE    DEAD. 

Envelop  the  body  in  a  sheet  thoroughly  satu- 
rated with  : — 

1.  Chloride  of  lime  in  solution,  four  per  cent. 

2.  Mercuric  chloride  in  solution,  i  :  500. 

3.  Carbolic  acid  in  solution,  five  per  cent. 


50  HYGIENE   OF   THE  SICK-ROOM. 

\ 

FOR    THE    SICK-ROOM    AND    HOSPITAL    WARDS. 

(a)  While  occupied,  wash  all  surfaces  with  : — 

1.  Mercuric  chloride  in  solution,  I  :  1000. 

2.  Carbolic  acid,  in  solution,  two  percent. 

($)  When  vacated,  fumigate  with  sulphur  dioxide 
for  twelve  hours,  burning  at  least  three  pounds  of 
sulphur  for  every  1000  cubic  feet  of  air-space  in 
th'e  room  ;  then  wash  all  surfaces  with  one  of  the 
above-mentioned  disinfecting  solutions,  and  after- 
ward with  soap  and  hot  water ;  finally,  throw  open 
doors  and  windows  and  ventilate  freely. 

In  reading  over  this  formidable  list  of  disinfect- 
ants the  nurse  may  well  be  puzzled  to  know  what 
to  choose  from  so  large  a  list.  This  list  has  not 
been  published  without  objections.  The  efficiency 
of  the  mercuric  chloride  solutions  has  at  times  been 
questioned  ;  the  fumigation  with  sulphur  in  a  closed 
room  has  also  been  viewed  with  skepticism  by  some. 
The  use  of  too  strong  a  solution  of  mercuric 
chloride  hardens  the  hands  to  an  unpleasant  degree, 
and,  as  is  now  fully  appreciated,  destroys  the  cut- 
ting edge  of  surgical  instruments.  In  general  the 
two  most  commonly  used  disinfectants  are  the  mer- 


INFECTION  AND   DISINFECTION.  51 

curie  chloride  solution,  i  :  1000,  and   the  carbolic 
acid  solution,  five  per  cent. 

The  same  American  Public  Health  Association, 
through  its  Chairman  of  the  Committee  on  Disin- 
fectants, has  prepared  a  report  which  is  con- 
sidered important  enough  to  be  reproduced  here 
verbatim. 

"  DISINFECTION    AND    DISINFECTANTS. 

"  The  object  of  disinfection  is  to  prevent  the 
extension  of  infectious  diseases  by  destroying  the 
specific  infectious  material  which  gives  rise  to  them. 
This  is  accomplished  by  the  use  of  disinfectants. 

"  There  can  be  no  partial  disinfection  of  such 
material ;  either  its  infecting  power  is  destroyed  or 
it  is  not.  In  the  latter  case  there  is  a  failure  to 
disinfect.  Nor  can  there  be  any  disinfection  in  the 
absence  of  infectious  material. 

"  It  has  been  proved  for  several  kinds  of  infectious 
material  that  its  specific  infecting  power  is  due  to 
the  presence  of  living  micro-organisms,  known  in  a 
general  way  as  "  disease  germs  ;  "  and  practical  sani- 
tation is  now  based  upon  the  belief  that  the  infect- 
ing agents  in  all  kinds  of  infectious  material  are  of 


52  HYGIENE   OF   THE  SICK-ROOM. 


this  nature.  Disinfection,  therefore,  consists  es- 
sentially in  the  destruction  of  disease  germs. 

"  Popularly,  the  term  disinfection  is  used  in  a  much 
broader  sense.  Any  chemical  agent  which  de- 
stroys or  masks  bad  odors,  or  which  arrests  putre- 
factive decomposition,  is  spoken  of  as  a  disinfectant. 
And  in  the  absence  of  any  infectious  disease  it  is 
common  to  speak  of  disinfecting  a  foul  cesspool  or 
a  bad-smelling  stable  or  privy-vault. 

"  This  popular  use  of  the  term  has  led  to  much 
misapprehension,  and  the  agents  which  have  been 
found  to  destroy  bad  odors — deodorizers — or  to 
arrest  putrefactive  decomposition —  antiseptics — 
have  been  confidently  recommended  and  extensively 
used  for  the  destruction  of  disease  germs  in  the 
excreta  of  patients  with  cholera,  typhoid  fever,  etc. 

"  The  injurious  consequences  which  are  likely  to 
result  from  such  misapprehension  and  misuse  of 
the  word  disinfect  will  be  appreciated  when  it  is 
known  that  recent  researches  have  demonstrated 
that  many  of  the  agents  which  have  been  found 
useful  as  deodorizers  or  as  antiseptics  are  entirely 
without  value  for  the  destruction  of  disease  germs. 

"  This    is    true,     for    example,    as     regards   the 


INFECTION  AND  DISINFECTION.  53 

sulphate  of  iron,  or  copperas,  a  salt  which  has 
been  extensively  used  with  the  idea,  that  it  is 
a  valuable  disinfectant.  As  a  matter  of  fact, 
sulphate  of  iron  in  saturated  solution  does  not 
destroy  the  vitality  of  disease  germs  or  the 
infecting  power  of  material  containing  them. 
This  salt  is,  nevertheless,  a  very  valuable  an- 
tiseptic, and  its  low  price  makes  it  one  of  the 
most  available  agents  for  the  arrest  of  putre- 
factive decomposition. 

"Antiseptic  agents,  however,  exercise  a  re- 
straining influence  upon  the  development  of 
disease  germs,  and  their  use  during  epidemics 
is  to  be  recommended  when  masses  of  organic 
material  in  the  vicinity  of  human  habitations 
cannot  be  completely  destroyed,  or  removed,  or 
disinfected. 

"  While  an  antiseptic  agent  is  not  necessarily 
a  disinfectant,  all  disinfectants  are  antiseptics ; 
for  putrefactive  decomposition  is  due  to  the 
development  of  "  germs  "  of  the  same  class  as 
that  to  which  disease  germs  belong,  and  the 
agents  which  destroy  the  latter  also  destroy 
the  bacteria  of  putrefaction  when  brought  in 


54  HYGIENE   OF   THE  SICK-ROOM. 


contact  with  them  in  sufficient  quantity,  or 
restrain  their  development  when  present  in 
smaller  amounts.  A  large  number  of  the  pro- 
prietary "  disinfectants,"  so-called,  which  are  in 
the  market  are  simply  deodorizers  or  antiseptics, 
of  greater  or  less  value,  and  are  entirely  un- 
trustworthy for  disinfecting  purposes. 

"  Antiseptics  are  to  be  used  at  all  times  when 
it  is  impracticable  to  remove  filth  from  the 
vicinity  of  human  habitations,  but  they  are  a 
poor  substitute  for  cleanliness.  During  the 
prevalence  of  epidemic  diseases,  such  as  yellow 
fever,  typhoid  fever,  and  cholera,  it  is  better  to 
use  in  privy-vaults,  cess-pools,  etc.,  those  anti- 
septics which  are  also  disinfectants,  i.  e.,  ger- 
micides ;  and  when  the  contents  of  such  recep- 
tacles are  known  to  be  infected,  this  becomes 
imperative. 

"  Still  more  important  is  the  destruction  at  our 
seaport  quarantine  stations  of  infectious  material 
which  has  its  origin  outside  of  the  boundaries 
of  the  United  States,  and  the  destruction,  within 
our  boundaries,  of  infectious  material  given  off 
from  the  persons  of  those  attacked  with  any 


INFECTION  AND   DISINFECTION.  55 


infectious  disease,  whether  imported  or  of  indig- 
enous origin. 

"  In  the  sick-room  we  have  disease  germs  at 
an  advantage,  for  we  know  where  to  find  them 
as  well  as  how  to  kill  them.  Having  this 
knowledge,  not  to  apply  it  would  be  criminal 
negligence,  for  our  efforts  to  restrict  the  exten- 
sion of  infectious  diseases  must  depend  largely 
upon  the  proper  use  of  disinfectants  in  the 
sick-room. 

"  GENERAL    DIRECTIONS. 

"  Disinfection  of  Excreta,  etc.  The  infectious 
character  of  the  dejections  of  patients  suffering 
from  cholera  and  from  typhoid  fever  is  well  es- 
tablished ;  and  this  is  true  of  mild  cases  and  of 
the  earliest  stages  of  these  diseases  as  well  as 
of  severe  and  fatal  cases.  It  is  probable  that 
epidemic  dysentery,  tuberculosis,  and  perhaps 
diphtheria,  yellow  fever,  scarlet  fever,  and  typhus 
fever  may  also  be  transmitted  by  means  of  the 
alvine  discharges  of  the  sick.  It  is,  therefore, 
of  the  first  importance  that  these  should  be  dis- 
infected. In  cholera,  diphtheria,  yellow  fever,  and 
scarlet  fever  all  vomited  material  should  also  be 


56  HYGIENE   OF   THE  SICK-ROOM. 


looked  upon  as  infectious.  And  in  tuberculosis, 
diphtheria,  scarlet  fever,  and  infectious  pnaumo- 
nia  the  sputa  of  the  sick  should  be  disinfected 
or  destroyed  by  fire.  It  seems  advisable  also 
to  treat  the  urine  of  patients  sick  with  an  infec- 
tious disease  with  one  of  the  disinfecting  solu- 
tions below  recommended. 

"  Chloride  of  lime  or  bleaching  powder  is  perhaps 
entitled  to  the  first  place  for  disinfecting  excreta,  on 
account  of  the  rapidity  of  its  action.  The  follow- 
ing standard  solution  is  recommended  : — 

"Dissolve  chloride  of  lime  of  the  best  quality*  in  pure 
water,  in  the  proportion  of  six  ounces  to  the  gallon. 

"  Use  one  quart  of  this  solution  for  the  disinfection 
of  each  discharge  in  cholera,  typhoid  fever,  etc.f 
Mix  well  and  leave  in  the  vessel  for  at  least  one 
hour  before  throwing  into  privy-vault  or  water- 


*  Good  chloride  of  lime  should  contain  at  least  twenty-five  per  cent, 
of  available  chlorine.  It  may  be  purchased  by  the  quantity  at  three 
and  a  half  cents  per  pound.  The  cost  of  the  standard  solution 
recommended  is  therefore  but  little  more  than  one  cent  a  gallon. 
A  clear  solution  may  be  obtained  by  filtration  or  by  decantation,  but 
the  insoluble  sediment  does  no  harm,  and  this  is  an  unnecessary 
refinement. 

f  For  a  very  copious  discharge,  use  a  large  quantity. 


INFECTION  AND  DISINFECTION.  57 

closet.  The  same  directions  apply  for  the  disin- 
fection of  vomited  matters.  Infected  sputum 
should  be  discharged  directly  into  a  cup  half  full 
of  the  solution.  A  five  per  cent,  solution  of  car- 
bolic acid  may  be  used  instead  of  the  chloride  of 
lime  solution,  the  time  of  exposure  to  the  action 
of  the  disinfectant  being  four  hours. 

"  Disinfection  of  the  Person.  The  surface  of  the 
body  of  a  sick  person,  or  of  his  attendants,  when 
soiled  with  infectious  discharges,  should  be  at  once 
cleansed  with  a  suitable  disinfecting  agent.  For 
this  purpose  solution  of  chlorinated  soda  (liquor 
sodas  chlorinatae)  diluted  with  nine  parts  of 
water,  or  the  standard  solution  of  chloride  of 
lime  diluted  with  three  parts  of  water,  may  be 
used.  A  two  per  cent,  solution  of  carbolic  acid 
is  also  suitable  for  this  purpose,  and  under  proper 
medical  supervision  the  use  of  a  solution  of  cor- 
rosive sublimate — I  :  1000 — is  to  be  recommended. 

"  In  diseases  like  small-pox  and  scarlet  fever,  in 
which  the  infectious  agent  is  given  off  from  the 
entire  surface  of  the  body,  occasional  ablutions 
with  the  above-mentioned  solution  of  chlorinated 

soda  are  recommended. 
5 


58  HYGIENE   OF  THE  SICK-ROOM. 


"  In  all  infectious  diseases  the  bo'dy  of  the  dead 
should  be  enveloped  in  a  sheet  saturated  with  the 
standard  solution  of  chloride  of  lime,  or  with  a 
five  per  cent,  solution  of  carbolic  acid,  or  a  I  :  500 
solution  of  corrosive  sublimate. 

'  'Disinfection  of  Clothing.  Boiling  forhalfanhour 
will  destroy  the  vitality  of  all  known  disease  germs, 
and  there  is  no  better  way  of  disinfecting  clothing 
or  bedding  which  can  be  washed  than  to  put  it 
through  the  ordinary  operations  of  the  laundry. 
No  delay  should  occur,  however,  between  the 
time  of  removing  soiled  clothing  from  the  person 
or  bed  of  the  sick  and  its  immersion  in  boiling 
water,  or  in  one  of  the  following  solutions  until 
this  can  be  done  : — 

"  Corrosive  sublimate,  one  drachm  to  the  gallon 
of  water  (about  I  :  1000),  or, 

"  Carbolic  acid,  pure,  one  ounce  to  the  gallon  of 
water  (i  :  128). 

"The  articles  to  be  disinfected  must  be  thor- 
oughly soaked  with  the  disinfecting  solution  and 
left  in  it  for  at  least  two  hours,  after  which  they 
may  be  wrung  out  and  sent  to  the  wash. 

"  N.  B.    Solutions  of  corrosive  sublimate  should 


INFECTION  AND  DISINFECTION.  59 

not  be  placed  in  metal  receptacles,  for  the  salt  is 
decomposed  and  the  mercury  precipitated  by  con- 
tact with  copper,  lead,  or  tin.  A  wooden  tub  or 
earthen  crock  is  a  suitable  receptacle  for  such 
solutions. 

"  Clothing  or  bedding  which  cannot  be  washed 
should  be  disinfected  by  steam  in  a  properly  con- 
structed disinfection  chamber.  In  the  absence  of  a 
suitable  steam  disinfecting  apparatus,  infected  cloth- 
ing and  bedding  should  be  burned. 

"Disinfection  of  the  Sick-room. — In  the  sick-room 
no  disinfectant  can  take  the  place  of  free  ventila- 
tion and  cleanliness.  It  is  an  axiom  in  sanitary 
science  that  it  is  impracticable  to  disinfect  an  occu- 
pied apartment  for  the  reason  that  disease  germs 
are  not  destroyed  by  the  presence  in  the  atmos- 
phere of  any  known  disinfectant  in  respirable 
quantity.  Bad  odors  may  be  neutralized,  but  this 
does  not  constitute  disinfection  in  the  sense  in 
which  the  term  is  here  used.  These  bad  odors  are, 
for  the  most  part,  an  indication  of  want  of  cleanli- 
ness or  of  proper  ventilation ;  and  it  is  better  to 
turn  contaminated  air  out  of  the  window  or  up  the 
chimney  than  to  attempt  to  purify  it  by  the  use  of 


60  HYGIENE   OF  THE  SICK-ROOM. 


volatile  chemical  agents,  such  as  carbolic  acid,  chlor- 
ine, etc.,  which  are  all  more  or  less  offensive  to  the 
sick,  and  are  useless  so  far  as  disinfection — properly 
so  called — is  concerned. 

"  When  an  apartment  which  has  been  occupied 
by  a  person  sick  with  an  infectious  disease  has  been 
vacated,  it  should  be  disinfected.  The  object  of 
disinfection  in  the  sick-room  is  mainly  the  destruc- 
tion of  infectious  material  attached  to  surfaces,  or 
deposited  as  dust  upon  window  ledges,  in  crevices, 
etc.  If  the  room  has  been  properly  cleansed  and 
ventilated  while  still  occupied  by  the  sick  person, 
and  especially  if  it  was  stripped  of  carpets  and 
unnecessary  furniture  at  the  outset  of  his  attack, 
the  difficulties  of  disinfection  will  be  greatly  re- 
duced. All  surfaces  should  be  thoroughly  washed 
with  the  standard  solution  of  chloride  of  lime 
diluted  with  three  parts  of  water,  or  with  i  :  1000 
solution  of  corrosive  sublimate.  The  walls  and 
ceiling,  if  plastered,  should  be  subsequently  treated 
with  a  lime-wash.  Especial  care  must  be  taken 
to  wash, away  all  dust  from  window  ledges  and 
other  places  where  it  may  have  settled,  and  thor- 
oughly to  cleanse  crevices  and  out-of-the-way 


INFECTION  AND  DISINFECTION.  61 


places.  After  this  application  of  the  disinfecting 
solution,  and  an  interval  of  twenty-four  hours  or 
longer  for  free  ventilation,  the  floors  and  wood- 
work should  be  well  scrubbed  with  soap  and  hot 
water,  and  this  should  be  followed  by  a  second 
more  prolonged  exposure  to  fresh  air,  admitted 
through  open  doors  and  windows. 

"As  an  additional  precaution,  fumigation  with  sul- 
phurous acid  gas  is  to  be  recommended,  especially 
for  rooms  which  have  been  occupied  by  patients 
with  small-pox,  yellow  fever,  scarlet  fever,  diph- 
theria, and  typhus  fever.  But  fumigation  with 
sulphurous  acid  gas  alone,  as  commonly  practiced, 
cannot  be  relied  upon  for  the  disinfection  of  the 
sick-room  and  its  contents,  including  bedding,  furni- 
ture, infected  clothing,  etc.,  as  is  popularly  be- 
lieved. 

"  When  fumigation  is  practiced,  it  should  precede 
the  general  washing  with  a  disinfecting  solution, 
heretofore  recommended.  To  insure  any  results 
of  value,  it  will  be  necessary  to  close  the  apartment 
to  be  disinfected  as  completely  as  possible  by  stop- 
ping all  apertures  through  which  the  gas  might 
escape,  and  to  burn  not  less  than  three  pounds  of 


62  HYGIENE   OF  THE  SICK-ROOM. 

sulphur  for  each  thousand  cubic  feet  of  air  space  in 
the  room.  To  secure  complete  combustion  of  the 
sulphur,  it  should  be  placed,  in  powder  or  in  small 
fragments,  in  a  shallow  iron  pan,  which  should  be  set 
upon  a  couple  of  bricks  in  a  tub  partly  filled  with 
water,  to  guard  against  fire.  The  sulphur  should 
be  thoroughly  moistened  with  alcohol  before  ignit- 
ing it. 

''Disinfection  of  Privy-vaults,  Cess-pools,  etc.  When 
the  excreta  (not  previously  disinfected)  of  patients 
with  cholera  or  typhoid  fever  have  been  thrown 
into  a  privy-vault,  this  is  infected,  and  disinfection 
should  be  resorted  to  as  soon  as  the  fact  is  discov- 
ered, or  whenever  there  is  reasonable  suspicion 
that  such  is  the  case.  It  will  be  advisable  to  take 
the  same  precautions  with  reference  to  privy-vaults 
into  which  the  excreta  of  yellow  fever  patients 
have  been  thrown,  although  we  do  not  definitely 
know  that  this  is  infectious  material. 

"  For  this  purpose  the  standard  solution  of  chlor- 
ide of  lime  may  be  used  in  quantity  proportioned 
to  the  amount  of  material  to  be  disinfected,  but 
where  this  is  considerable  it  will  scarcely  be  practi- 
cable to  sterilize  the  whole  mass.  The  liberal  and 


INFECTION  AND  DISINFECTION.  63 


repeated  use  of  this  solution,  or  of  a  five  per  cent, 
solution  of  carbolic  acid,  will,  however,  disinfect 
the  surface  of  the  mass,  and  is  especially  to  be 
recommended  during  the  epidemic  prevalence  of 
typhoid  fever  or  of  cholera. 

"All  exposed  portions  of  the  vault,  and  the 
wood-work  above  it,  should  be  thoroughly  washed 
down  with  the  disinfecting  solution.  Instead  of 
the  disinfecting  solutions  recommended,  chloride 
of  lime  in  powder  may  be  daily  scattered  over  the 
contents  of  the  privy-vault. 

"Disinfection  of  higesta.  It  is  well  established 
that  cholera  and  typhoid  fever  are  very  frequently, 
and  perhaps  usually,  transmitted  through  the  med- 
ium of  infected  water  or  articles  of  food,  and  espe- 
cially milk.  Fortunately,  we  have  a  simple  means 
at  hand  for  disinfecting  such  infected  fluids.  This 
consists  in  the  application  of  heat.  The  boiling 
temperature  maintained  for  half  an  hour  kills  all 
known  disease  germs.  So  far  as  the  germs  of 
cholera,  yellow  fever,  and  diphtheria  are  concerned, 
there  is  good  reason  to  believe  that  a  temperature 
considerably  below  the  boiling  point  of  water  will 
destroy  them.  But  in  order  to  keep  on  the  safe 


64  HYGIENE   OF  THE  SICK-ROOM. 


side,  it  is  best  not  to  trust  to  anything  short  of  the 
boiling  point  (212°  F.)  when  the  object  is  to  disin- 
fect food  or  drink  which  is  open  to  the  suspicion 
of  containing  the  germs  of  any  infectious  disease. 
"  During  the  prevalence  of  an  epidemic  of  cholera 
it  is  well  to  boil  all  water  for  drinking  purposes. 
After  boiling,  the  water  may  be  filtered,  if  necessary, 
to  remove  sediment  and  then  cooled  with  pure  ice, 
if  desired." 


CHAPTER  III. 

TUBERCULOSIS. 

Tuberculosis  is  one  of  the  most  dreadful  diseases 
that  infest  the  human  race,  attacking  so  many,  ir- 
respective of  color,  sex,  or  age.  It  shows  itself  in 
various  ways,  and  its  power  is  so  great  that  it  causes 
more  than  one-seventh  of  all  the  deaths  that  occur. 
It  is  a  condition  which  has  only  been  clearly  un- 
derstood since  the  discovery  of  the  bacillus  tuber- 
culosis in  1882  by  Koch.  From  this  discovery  we 
know  that  the  disease,  whether  affecting  the  joints, 
skin,  or  internal  organs,  such  as  the  lungs  and  in- 
testines, is  identical,  and  always  due  to  the  presence 
of  this  specific  organism.  This  disease  is  familiar 
to  most  persons  in  the  form  of  pulmonary  con- 
sumption, a  disease  which  has  been  so  universally 
fatal  to  mankind. 

After  many  years  of  work  and  investigation, 
proving  each  step  clearly  and  carefully,  Koch  an- 
nounced to  the  medical  world  the  discovery  of  the 
tubercle  bacillus.  After  numerous  examinations 

65 


66  HYGIENE   OF   THE  SICK-ROOM. 

of  the  expectoration  and  lung  substance  from  tu- 
berculous patients,  both  under  the  microscope  and 
by  cultivation,  he  succeeded  in  isolating  a  short, 
slender  bacillus,  which  he  thought  was  the  specific 
germ  of  tuberculosis.  Then  he  completed  his  chain 
of  evidence  by  taking  a  pure  cultivation  of  the 
bacilli  and  inoculating  it  into  a  susceptible  animal, 
such  as  a  guinea  pig  or  monkey,  and  produced  the 
same  disease  in  these  animals  and  found  the  same 
organism  in  them.  After  this  discovery  was  once 
received  by  the  medical  world  it  began  to  be  ap- 
preciated. To  be  sure,  many  skeptics  asked,  as 
always  is  the  case  with  such  discoveries,  what  was 
the  use  of  this  discovery  if  we  could  not  kill  the 
bacillus;  and  others  said  that  whatever  was  strong 
enough  to  kill  the  bacillus  was  powerful  enough  to 
destroy  the  patient. 

The  advantage  of  the  discovery  of  this  bacillus 
from  a  diagnostic  standpoint  is  invaluable.  This 
may  be  very  readily  seen.  A  case  of  suspected 
pulmonary  consumption  presents  itself;  the  patient 
is  questioned,  the  history  of  the  case  learned,  all 
the  symptoms,  the  signs  noted  and  a  careful  exami- 
nation both  by  auscultation  and  percussion  is 


TUBERCULOSIS.  67 


made,  and  yet  no  positive  results  are  reached ;  then 
a  portion  of  the  sputum,  particularly  that  expecto- 
rated in  the  morning  and  free  from  food,  is  exam- 
ined microscopically  in  the  manner  above  described 
by  aid  of  the  aniline  colors,  and  if  the  bacilli  are 
present  (and  this  method  will  generally  decide),  we 
may  be  sure  of  the  cause  of  the  disease  and  treat 
it  early  with  the  best  possible  chances  for  success. 
Tuberculosis,  therefore,  being  a  disease  caused  by 
a  specific  bacillus,  it  is  our  duty  to  attempt  to  pre- 
vent the  spread  of  this  disease  as  far  as  it  lies  in  our 
power ;  this  we  can  in  great  measure  do  by  trying 
to  prevent  the  spread  of  the  bacillus.  "  But  how  is 
this  possible  ?  "  one  may  ask.  A  consumptive  person 
who  goes  along  the  streets  or  in  the  cars  may 
expectorate  matter  in  which  there  are  myriads  of 
bacilli.  As  long  as  they  are  moist  they  are  not 
dangerous,  but  let  them  become  dry  and  be  caught 
up  by  the  wind  and  carried  about,  and  they  are  then 
easily  spread.  Still,  as  said  above,  the  bacillus 
may  die  on  being  exposed  to  drying,  but  the  spores 
retain  their  vitality  a  long  time  and  only  await  a 
proper  soil  to  bud  and  germinate.  This  matter  in 
the  expectoration  is  then  dried,  caught  up  by 


68  HYGIENE   OF  THE  SICK-ROOM. 


currents  of  air  and  tossed  about,  or  it  attaches  itself 
to  minute  particles  of  dust.  Such  dust  is  very 
easily  inhaled  by  one  exposed  to  it,  and  if  such 
a  one  be  susceptible,  as  we  say,  to  tuberculosis,  the 
bacilli  or  their  spores  find  a  lodging  place  in  the 
lungs  of  this  person  and  multiply  and  start  the 
disease.  It  is  undoubtedly  true  that  consumption 
is  very  often  spread  in  this  way.  It  is  possible  that 
a  hospital  containing  many  consumptive  patients 
may  become  a  centre  of  infection. 

As  we  cannot  manage  all  those  patients  who  go 
about  and  spread  the  disease,  we  must  turn  our 
attention  to  those  under  control.  With  these  we 
must  be  particularly  careful  how  the  expectoration 
is  disposed  of.  If  the  patient  be  able  to  expecto- 
rate in  a  suitable  vessel,  that  vessel  should  always 
contain  some  antiseptic  solution,  as  the  bichloride 
of  mercury,  i  :  1000,  and  when  removed  the  vessel 
should  not  be  washed  out  first,  but  should  be  put 
in  a  steam  sterilizer  or  in  the  oven  and  be  exposed 
to  a  high  temperature  for  several  hours.  This 
certainly  kills  not  only  the  germs  of  tuberculosis, 
but  also  their  spores.  Those  patients  who  cannot 
raise  their  heads,  as  those  in  the  last  stages  of  con- 


TUBERCULOSIS.  69 


sumption,  are  obliged  to  use  handkerchiefs,  towels, 
etc.,  to  receive  the  expectoration.  In  these  cases 
it  is  preferable  to  use  small  pieces  of  old  linen 
which  may  be  at  once  burned ;  but  if  material  be 
used  which  it  is  not  feasible  to  destroy  by  fire,  it 
should  be  exposed  to  prolonged  boiling  or  be  put 
into  a  five  per  cent,  carbolic  acid  solution  for 
several  hours.  All  clothing  that  comes  in  contact 
with  consumptive  patients  should  be  boiled  for  at 
least  one  hour  before  being  washed,  and  should 
never  be  used  for  other  patients. 

While  the  sweat  and  the  breath  of  consumptive 
patients  have  never  been  known  to  contain  the 
bacillus,  and  are  therefore  not  contagious,  still,  the 
fact  that  the  poison  may  be  conveyed  from  the 
mouth  to  any  other  part  of  the  body,  should  be  suffi- 
cient to  insure  great  care  in  disposing  of  whatever 
wearing  apparel  is  used  by  them.  In  some  hospitals 
small  paper  cuspidors  mounted  in  tin  frames  are 
used,  and  the  paper  part  when  filled  is  removed 
and  burned.  This,  being  patented,  is  too  expensive 
for  a  large  hospital  ;  still  further,  the  tin  frames  are 
apt  to  become  contaminated,  and  being  in  constant 
use  are  apt  to  scatter  the  dried  sputum.  While  we 


70  HYGIENE   OF  THE  SICK-ROOM. 


may  not  believe  that  one  patient  in  a  hospital  ward 
can  catch  consumption  from  another,  still  we 
should  always  think  of  the  possible  danger,  and  re- 
member that  where  one  patient  or  person  is  predis- 
posed to  this  disease  by  some  hereditary  fault  or 
taint,  exposure  to  the  disease  may  light  up  the  first 
trouble. 

The  disease  may  find  its  way  into  the  body 
through  the  circulation,  through  the  lymphatics, 
or  it  may  be  taken  into  the  stomach,  or  else  by 
inhalation.  The  latter  is  the  most  probable  way. 
The  dried  spores  of  the  germ  are  carried  about  in 
the  air  with  the  dust,  and  gain  access  to  the  lungs 
of  some  unfortunate  susceptible  person  and  there 
"  take  root."  Infection  through  the  stomach  is 
rare,  as  the  hydrochloric  acid  contained  in  the  gas- 
tric juice  is  generally  strong  enough  to  destroy  the 
activity  of  the  bacillus.  Milk  and  meat,  especially 
beef,  may  contain  tubercle  bacilli,  the  former,  that 
is  milk,  often  giving  the  disease  to  infants,  but  con- 
tagion through  the  stomach  is,  fortunately,  as  stated 
above,  comparatively  rare.  Cases  in  which  tuber- 
culosis of  the  stomach  and  intestines  is  found  are 
usually  secondary  to  lung  tuberculosis,  and  this  is 


TUBERCULOSIS.  71 


probably  the  cause  of  the  disordered  condition  of 
the  tuberculous  patient  in  the  late  stages;  the 
disease  so  affects  the  digestion  that  the  gastric 
juice  is  not  strong  enough  or  abundant  enough  to 
cope  with  the  larger  amount  of  tubercular  sputum 
which  the  weak  patient  is  not  able  to  expectorate 
and  therefore  swallows ;  but  more  of  this  will  be 
considered  later  on. 

In  regard  to  the  infection  from  tuberculous  pa- 
tients one  thing  may  be  stated  here,  and  that  is,  as 
a  matter  of  fact,  the  trained  nurse,  considering  her 
occupation,  is  unusually  exempt  from  consumption, 
while  nurses  in  a  religious  order  too  often  fall  vic- 
tims to  this  disease.  This  is  explained  by  the  fact 
that  the  trained  nurse  always,  or  nearly  always,  gets 
the  proper  amount  of  rest  and  exercise,  especially 
in  a  well-regulated  hospital,  while  the  religious 
sister  may  be  on  duty  from  twelve  to  forty-eight 
hours  at  a  time  without  rest,  and  she  is  in  some 
orders  never  allowed  to  go  out  for  exercise.  In 
this  way  the  strength  is  overtaxed  and  attacks  of 
the  bacillus  tuberculosis  are  not  warded  off, 
because  the  system  is  not  equal  to  the  struggle. 
This  shows,  as  will  be  noted  later  on,  that  not 


72  HYGIENE   OF  THE  SICK-ROOM. 


only  exercise,  but  proper  ventilation,  is  an  impor- 
tant factor  in  preventing  consumption. 

So  important  has  the  necessity  for  prevention 
shown  itself  that  many  countries,  and  in  the 
United  States  many  of  the  cities,  have  enacted, 
and  actually  enforce  with  some  pretensions  to 
strictness,  certain  laws  for  the  prevention  of  the 
spread  of  this  disease.  While  New  York  City 
has  no  laws  on  the  subject,  the  following  rules  to 
be  observed  for  the  prevention  of  the  spread  of 
consumption  were  approved  by  the  Health  Depart- 
ment of  that  city  and  ten  thousand  copies  were 
ordered  to  be  printed  for  public  distribution  : — 

"  Pulmonary  consumption,  or  tuberculosis,  is 
directly  communicated  from  one  person  to  another. 
The  germ  of  the  disease  exists  in  the  expectoration 
of  persons  affected  with  it.  The  following  extract 
from  the  report  of  the  pathologists  of  the  Health 
Department  explains  the  means  by  which  the  dis- 
ease may  be  transmitted  : — 

" '  Tuberculosis  is  commonly  produced  in  the 
lungs  (which  are  the  organs  most  frequently  affected) 
by  breathing  air  in  which  living  germs  are  sus- 
pended as  dust.  The  material  which  is  coughed  up, 


TUBERCULOSIS.  73 


sometimes  in  large  quantities,  by  persons  suffering 
from  consumption  contains  these  germs  often  in 
enormous  numbers.  This  material  when  expecto- 
rated frequently  lodges  in  places  where  it  dries, 
as  on  the  street,  floors,  carpets,  handkerchiefs,  etc. 
After  drying  in  one  way  or  another  it  is  very  apt 
to  become  pulverized  and  float  in  the  air  as  dust 

"  By  observing  the  following  rules  the  danger  of 
catching  the  disease  will  be  reduced  to  a  mini- 
mum : — 

"  i.  Do  not  permit  persons  suspected  to  have  con- 
sumption to  spit  on  the  floor  or  on  cloths  unless 
the  latter  be  immediately  burned.  The  spittle  of 
persons  suspected  to  have  consumption  should  be 
caught  in  earthen  or  glass  dishes  containing  the 
following  solution :  Corrosive  sublimate,  I  part ; 
water,  1000  parts. 

"  2.  Do  not  sleep  in  a  room  occupied  by  a  person 
suspected  of  having  consumption.  The  living 
rooms  of  a  consumptive  patient  should  have  as 
little  furniture  as  practicable.  Hangings  should 
be  especially  avoided.  The  use  of  carpets,  rugs, 
etc.,  ought  always  to  be  avoided. 

"  3.  Do  not  fail  to  wash  thoroughly  the  eating 


74  HYGIENE   OF  THE  SICK-ROOM. 

utensils  of  a  person  suspected  of  having  consump- 
tion as  soon  after  eating  as  possible,  using  boiling 
water  for  the  purpose. 

"  4.  Do  not  mingle  the  unwashed  clothing  of  con- 
sumptive patients  with  similar  clothing  of  other 
persons. 

"  5.  Do  not  fail  to  catch  the  bowel  discharges 
of  consumptive  patients  with  diarrhoea  in  a 
vessel  containing  corrosive  sublimate,  I  part; 
water,  1000  parts. 

"  6.  Do  not  fail  to  consult  the  family  physician 
regarding  the  social  relations  of  persons  suffering 
from  suspected  consumption. 

"  7.  Do  not  permit  mothers  suspected  of  having 
consumption  to  nurse  their  offspring. 

"  8.  Household  pets  (animals  or  birds)  are  quite 
susceptible  to  tuberculosis ;  therefore  do  not 
expose  them  to  persons  afflicted  with  consump- 
tion ;  also,  do  not  keep,  but  destroy  at  once,  all 
household  pets  suspected  of  having  consump- 
tion, otherwise  they  may  give  it  to  human 
beings. 

"  9.  Do  not  fail  to  clean  thoroughly  the  floors, 
walls,  and  ceilings  of  the  living-  and  sleeping- 


TUBERCULOSIS.  75 


rooms  of  persons  suffering  from  consumption   at 
least  once  in  two  weeks." 

Of  course,  it  is  right  and  proper  to  enforce  such 
rules  as  strictly  as  possible,  but  while  such  rules 
may  be  enforced  in  well-managed  hospitals,  and 
in  some  private  families  where  the  scourge  of 
this  disease  has  shown  them  the  necessity  of  care, 
in  public  gatherings  and  especially  in  large  sum- 
mer and  winter  hotels,  in  the  United  States,  at 
least,  no  such  rules  are  dreamed  of,  and  in  such 
places  these  very  rules  are  violated  singly  and 
together,  and  in  sleeping  and  eating,  and  also  in 
the  public  rooms,  the  sick  and  the  well  come 
together  and  help  to  spread  the  disease.  This 
is  said  to  be  true  also  of  the  American  sleeping- 
cars. 


CHAPTER  IV. 

TYPHOID  FEVER. 

Typhoid  fever  is  a  disease  which  is  so  much 
better  understood  by  careful  study  of  the  patient 
that  in  many  cases  we  may  say  that  the  intelli- 
gent, observing  nurse  knows  more  about  the 
disease  than  the  physician,  for  she  sees  the  case 
throughout  the  whole  day  and  night  and  notes 
each  symptom,  while  the  physician  comes  in  only 
at  long  intervals,  and  usually  sees  the  patient 
under  the  most  favorable  circumstances,  for  few 
patients  fail  to  look  brighter  when  their  physician 
comes  in. 

Typhoid  fever  is  a  disease  in  which  drug  treat- 
ment seems  to  do  little,  and  where  intelligent 
nursing  does  much.  The  insidious  way  in  which 
the  disease  begins  and  the  gradual  onset  of  all 
the  symptoms  made  earlier  observers  suspect 
that  it  was  caused  by  a  slow  poison,  but  it  is 
only  comparatively  recently  that  the  typhoid 
bacillus  has  been  accepted  as  the  actual  cause  of 

76 


TYPHOID  FEVER.  77 

the  disease.  Eberth  and  Gaffky  have  done  the 
best  work  in  this  direction. 

The  specific  bacillus  is  a  short,  thick  rod,  which 
is  found  principally  in  the  small  intestines  and 
spleen.  The  poison  which  these  bacilli  produce 
gives  the  disease  that  typical  characteristic  called 
"typhoid"  or  "  stupid,"  for  the  patient  while  under 
the  influence  of  the  disease  usually  lies  in  a  stupid 
condition.  This  poison  is  disseminated  through- 
out the  whole  body,  while  the  bacilli  remain  in 
the  intestines  and  spleen.  It  is  also  the  active 
presence  of  these  bacilli  in  the  lower  end  of  the 
small  intestine  that  causes  in  fatal  cases  those 
extensive  ulcerations,  erosions,  and  perforations 
of  the  intestines  which  so  frequently  end  in 
peritonitis  and  death. 

From  the  way  in  which  many  persons  are 
attacked  in  the  same  family,  district,  and  commu- 
nity, it  has  become  pretty  well  settled  that  the 
materies  morbi  is  taken  in  by  the  mouth  with  the 
food  or  drink  ;  indeed,  there  is  scarcely  a  doubt 
but  that  the  poison  comes  from  the  drinking  water 
in  the  majority  of  cases.  This  has  been  proved 
so  often  that  some  look  to  the  drinking  water  in 


78  HYGIENE   OF  THE  SICK-ROOM. 


every  case  of  typhoid  fever.  Other  causes  may 
be  impure  milk  or  food.  It  may  be  in  the  flesh 
of  certain  animals,  or  it  may  be  scattered  with  the 
dust  or  come  in  contact  with  food,  especially 
when  taken  raw.  The  theory  that  typhoid  fever 
may  be  communicated  by  the  ground  has  still 
some  adherents,  and  it  cannot  be  denied  entirely. 
The  typhoid  bacillus,  when  taken  into  the 
stomach,  if  it  escape  the  gastric  juice,  sets  up 
an  inflammation  of  the  intestines,  and  finding 
a  lodging  place  there,  causes  a  diarrhoea.  It 
may  be  that  there  is  a  slight  diarrhoea  at  the 
time  the  bacillus  is  taken  into  the  body,  and  the 
altered  condition  of  the  intestinal  secretions  offers 
a  good  soil  for  it  to  grow  in.  Although  we  are 
quite  well  satisfied  as  to  the  bacillus,  still,  no 
one  ever  attempts  to  make  a  diagnosis  of  the 
case  by  looking  for  the  bacillus.  It  is  generally 
possible  to  make  a  diagnosis  from  the  signs, 
symptoms,  etc. ;  therefore  the  typhoid  bacillus  in 
this  connection  has  no  diagnostic  importance. 
Unfortunately,  the  characters  of  the  typhoid  ba- 
cillus are  so  indefinite,  and  the  difficulty  of  iden- 
tifying it  when  obtained  from  external  sources  so 


TYPHOID  FEVER.  79 


great,  that  little  advantage  has  hitherto  been 
gained  by  attempting  to  discover  it  in  water 
suspected  of  conveying  typhoid  fever. 

Another  very  frequent  source  of  the  infection, 
and  one  rarely  thought  of,  is  impure  ice.  We 
know  that  water  may  contain  typhoid  bacilli, 
and  we  also  know  that  this  water  may  freeze  and 
be  used  for  consumption ;  we  also  know  that  many 
bacilli,  particularly  the  typhoid  bacillus,  can  retain 
its  vitality  below  freezing  point,  although  it  cannot 
grow,  hence  ice,  which  was  at  one  time  supposed 
to  reject  all  impurities  on  freezing,  may  be  a  most 
dangerous  and  unsuspected  cause  of  typhoid  fever. 
It  may  be  noted  in  passing  that  some  bacteria  can- 
not grow  in  the  presence  of  oxygen  and  some  can- 
not live  without  it ;  to  the  latter  class  belongs  the 
typhoid  bacillus,  and  hence  in  that  ice  which  con- 
tains streaks  of  light  and  air  bubbles,  just  along 
the  border  of  these  air  streaks  the  bacilli,  if  pres- 
ent, are  particularly  abundant. 

While  one  case  of  typhoid  fever  is  not  usually 
contracted  from  another,  still,  we  know  that  the 
same  cause  which  produced  the  one  may  produce 
another,  hence,  when  one  or  more  cases  occur 


8o  HYGIENE   OF  THE  SICK-ROOM. 


in  the  same  house  or  neighborhood  it  is  our 
duty  to  look  for  the  cause.  All  doubtful  water, 
and,  indeed,  much  water  which  appears  innocent, 
should  be  first  boiled  and  then  filtered  before 
using ;  the  boiling  destroys  any  life  which  may 
exist  in  the  water,  while  the  filtering  makes  it 
pure.  Many  persons  drink  artificial  aerated  drink- 
ing waters  with  the  idea  that  they  are  free  from 
disease  germs  ;  they  are  just  as  impure  as  some 
other  waters,  and  while  the  carbonic  acid  gas  may 
act  destructively  to  some  of  the  bacilli,  still,  there 
are  enough  left  in  the  water  to  do  harm. 

When  typhoid  fever  breaks  out  in  a  community, 
prompt  measures  to  check  the  spread  of  the  dis- 
ease should  be  taken.  This  is  rarely  done  until 
large  numbers  have  been  attacked.  As  the  prin- 
cipal source  of  contagion  is  in  the  stools,  they 
should  be  rendered  as  harmless  as  possible  by  the 
use  of  proper  disinfectants  and  immediate  removal 
from  the  sick-room.  For  this  purpose  various 
chemicals  are  used  with  great  advantage,  such 
as  the  chloride  of  lime,  four  per  cent. ;  milk  of 
lime  in  the  form  mentioned  on  page  43 ;  carbolic 
acid,  five  per  cent.  The  disinfectant  should  be 


TYPHOID  FEVER.  81 

thoroughly  mixed  with  the  stools  and  allowed 
to  stand  four  hours.  This  careful  disinfection 
is  necessary  to  prevent  the  contamination  of 
drinking  water.  We  know  that  it  is  not  an  un- 
common thing  to  notice  in  the  country  and  in 
small  scattered  villages  that  the  well  or  cistern 
containing  the  drinking  water  is  at  a  lower  level 
than  the  cess-pool,  and  if  the  soil  be  favorable, 
as  it  often  is,  the  dangerous  contamination  may 
take  place  by  the  percolation  of  disease  germs 
from  the  cess-pool  to  the  drinking  water,  and 
even  in  cases  where  the  cess-pool  is  at  a  lower 
level  than  the  source  of  drinking-water  supply, 
the  soil  around,  becoming  soaked  with  faecal 
matter,  may  convey  the  poison,  by  capillary  at- 
traction against  gravity,  to  the  drinking  water. 

Many  of  our  large  cities  and  some  small  ones, 
too,  are  never  free  from  typhoid  fever,  and  at 
stated  intervals  suffer  from  severe  epidemics  of 
this  disease.  This  is  noticed  particularly  in  cities 
which  are  situated  on  rivers,  and  which  rely  prin- 
cipally for  their  watef  supply  upon  these  rivers. 
Now,  many  cities  in  taking  their  water  supply 
from  these  rivers  take  with  it  a  part  of  the 


82  HYGIENE   OF  THE  SICK-ROOM. 


sewage  from  the  towns  above  them  on  the  same 
river.  It  is  said  by  some  that  rivers  purify  them- 
selves after  a  flow  of  a  few  miles,  jDut  opinions 
differ  widely  on  this  point.  Parkes,  in  his  work 
on  hygiene,  says  that  purification  takes  place 
by  the  oxidation  of  the  dangerous  organic  ma- 
terial, by  deposition  of  the  suspended  material, 
carrying  with  it  some  of  the  organic  impurities, 
or  by  the  agency  of  organisms  in  the  water,  as 
fish,  water  plants,  or  the  more  minute  algae,  some 
forms  of  which  possibly  feed  upon  or  destroy  the 
as  yet  unrecognized  "  somethings "  which  cause 
disease.  This  purification  depends  on  the  rapidity 
of  the  flow  and  several  other  conditions,  and 
Parkes  adds  that  while  rivers  at  their  source 
may  be  a  safe  means  of  supply,  and  that  those 
that  have  once  received  sewage  may,  perhaps,  be 
safe  if  they  have  flowed  for  some  distance,  the  use 
of  water  from  such  streams  is  not  advisable  if  any 
better  supply  can  be  obtained.  Without  going  into 
this  further,  it  can  readily  be  seen  how  contami- 
nated water  and  ice  may  spread  this  disease. 

While  typhoid  fever  is  never  absent  from  large 
cities,  it  is  proportionately  more  common  in    the 


TYPHOID  FEVER.  83 


country  and  in  villages,  for  the  very  reason  that  in 
the  latter  the  water  supply  is  not  under  control,  as 
it  is  in  the  cities. 

The  best  cure  for  this  disease  is  not  to  let  it  oc- 
cur, for  of  all  preventable  diseases,  with  the  excep- 
tion of  small-pox,  typhoid  fever  is  one  that  could 
almost  always  be  prevented.  Some  localities  are 
without  the  proper  water  supply  and  others  need 
good  drainage ;  both  of  these  combined  should 
keep  out  typhoid  fever  entirely,  while  the  lack  of 
either  one  is  no  safeguard.  Not  many  years  ago 
in  the  city  of  Munich,  in  Germany,  typhoid  fever 
was  so  prevalent  that  strangers  hardly  dared  to  re- 
main there  for  any  length  of  time,  while  now  this 
disease  is  so  rare  there  that  it  is  with  great  diffi- 
culty the  medical  schools  can  find  a  sufficient 
number  of  typhoid  cases  for  clinical  teaching. 
This  shows  what  scientific  sanitation  can  do. 

One  not  uncommon  source  of  infection  is  from 
water-closets  in  bad  repair.  A  family  locks  up 
their  city  house  for  the  summer  months,  and  in  all 
this  time  the  water  in  the  water-closet  pans,  evapo- 
rating, gives  a  clear  opening  from  the  cess-pools, 
wells,  or  sewers  to  the  rooms  of  the  house,  and  any 


84  HYGIENE   OF  THE  SICK-ROOM. 

backward  currents  of  air  may  carry  dried  particles 
into  the  rooms.  It  is  very  easy  to  see  that  in  this 
way  djsease  germs  may  be  blown  into  the  rooms 
and  lie  in  wait  for  these  unfortunate  house-owners 
on  their  return,  one  or  more  of  whom  may  be  at- 
tacked by  some  disease  which  they  attribute  to  the 
malaria  of  the  place,  usually  a  summer  resort,  they 
have  just  left. 

Besides  the  disinfectants  above  named,  the  dry 
chloride  of  lime,  sprinkled  into  impure  vessels,  cess- 
pools, etc.,  is  amply  sufficient  to  destroy  all  bacilli. 
All  clothing  from  typhoid  patients  should  be  care- 
fully boiled  before  washing.  In  this  disease,  as  in 
pulmonary  consumption,  great  care  should  be  taken 
not  to  allow  the  clothing  from  the  sick  to  remain  in 
the  ward  or  room  after  removal  from  the  patient. 
It  is  a  great  temptation  for  the  nurse  to  let  them 
lie  for  a  while  near  the  bed  and  possibly  shake 
them  in  the  room.  They  should  be  carefully  rolled 
up  and  not  even  shaken  in  the  air,  but  immersed  at 
once  in  boiling  water  for  one  or  two  hours,  or  in 
one  of  the  disinfecting  solutions  given  above,  pre- 
ferably carbolic  acid  five  per  cent. 


CHAPTER  V. 

TYPHUS  FEVER. 

For  a  long  time  typhus  and  typhoid  fever  were 
not  distinguished,  but  a  careful  study  of  these  two 
diseases,  made  not  so  many  years  ago,  showed  not 
only  many  points  of  similarity  but  many  points  of 
difference.  The  term  typhus  tends  to  become 
confusing  when  we  consider  that  the  Germans  use 
it  when  they  mean  what  we  call  typhoid. 

Typhus  fever  is  not  endemic  in  this  country,  and 
only  occurs  when  cases  are  brought  from  other 
countries.  It  tends  to  spread  where  there  are 
crowds  of  people  in  an  unsanitary  condition.  It 
has  received  such  names  as  ship  fever,  hospital 
fever,  jail  fever,  camp  fever,  spotted  fever,  etc.,  etc. 
Its  onset  is  very  sudden  and  it  is  very  contagious 
at  short  distances,  but  it  is  not  believed  that  the 
clothes  of  the  patient  will  carry  the  disease.  Still, 
this  is  not  decided.  At  any  rate,  those  coming  in 
contact  with  typhus  patients  are  very  likely  to  con- 
tract the  disease.  It  is  never  absent  from  some 

85 


86  HYGIENE   OF  THE  SICK-ROOM. 


countries  and  has  only  occurred  as  epidemic  in 
parts  of  this  country  where  it  was  brought  in  by 
ships  from  Ireland  and  other  places. 

The  micro-organism  causing  the  disease  is  not 
known.  As  the  beginning  of  the  disease  is  very 
sudden,  as  few  escape  it  who  come  within  the 
range  of  contagion,  and  as  it  is  rapidly  fatal  in  so 
many  cases,  the  methods  of  precaution  should  be 
prompt.  They  are,  immediate  isolation  of  the  pa- 
tient and  attendants,  strict  quarantine  of  the  room 
and  even  of  the  house,  and  the  burning  up  of  the 
clothes  and  other  articles  used,  if  feasible.  It  has 
been  advised  to  keep  the  patients  in  large  and  airy 
rooms.  This  is  good  advice  in  almost  all  diseases, 
but  particularly  in  typhus,  as  the  germ  of  the  disease, 
although  very  virulent,  is  rendered  less  dangerous 
by  dilution  with  fresh  air,  and  because,  as  stated 
above,  the  area  of  contagion  is  very  small.  No  es- 
pecial directions  are  needed  in  this  case  which  are 
not  given  in  treating  of  typhoid  fever. 


CHAPTER  VI. 

ASIATIC  CHOLERA. 

Asiatic  cholera  is  a  disease  so  rarely  met  with  in 
the  United  States,  thanks  to  our  cleanliness  and 
good  sanitation,  that  it  need  not  be  considered  very 
extensively  here.  The  disease  has  almost  invari- 
ably been  traced  back  to  India,  from  which  place 
it  follows  the  course  of  trade,  of  travelers,  of  pil- 
grims, or  of  armies,  moving  either  by  sea  or  by 
land.  The  last  epidemic  of  cholera  in  Europe  cost 
that  country  250,000  lives,  which  represents  in 
money  a  loss  of  $8,000,000,  besides  the  loss  en- 
tailed by  enforced  idleness  due  to  the  paralysis  of 
trade. 

It  is,  like  typhoid  fever,  a  disease  associated  with 
unsanitary  conditions,  with  filth  and  carelessness, 
and  hence  under  properly  existing  circumstances 
an  epidemic  of  Asiatic  cholera  should  never  occur. 
Like  typhoid  fever,  also,  the  spread  of  cholera 
after  its  introduction  into  a  locality  is  associated 
with  contaminated  water  supply,  filthy  habits,  and 

87 


88  HYGIENE   OF  THE  SICK-ROOM. 


bad  personal  and  domestic  hygiene.  It  is  conveyed 
by  personal  effects  and  their  washing  through  the 
water  and  through  certain  kinds  of  food,  but  it 
does  not  seem  to  be  transmissible  through  the  air 
to  any  great  distance.  There  is  some  evidence 
that  the  soil  of  a  locality  may  become  infected 
with  the  specific  germ  of  cholera.  There  has 
been  much  time  and  study  spent  investigating  the 
specific  cause  of  Asiatic  cholera,  and  the  majority 
of  those  that  pretend  to  know  anything  about  the 
subject  consider  the  so-called  comma  bacillus  as 
discovered  by  Koch  as  the  specific  organism.  This 
is  a  slightly  curved  bacillus  (or  spirillum)  which 
grows  out  to  long,  spiral  threads  and  divides,  each 
piece  resembling  a  comma. 

The  disease  attacks  principally  those  predisposed 
to  it,  and  the  lesion  is  found  in  the  intestinal  canal. 
As  with  typhoid  fever,  the  disease  germ  resides 
in  the  dejecta,  which  are  the  source  of  infec- 
tion. These,  coming  into  contact  with  food, 
clothing,  and  especially  drinking  water,  convey 
the  disease  further.  This  has  been  the  history 
of  the  disease  in  the  Eastern  countries  where 
it  was  most  fatal.  The  people,  understanding 


ASIATIC  CHOLERA.  89 

little  or  caring  little  for  sanitary  principles, 
emptied  the  house  waste  and  water  closet  con- 
tents into  the  streams  or  on  the  ground  near 
the  streams  or  wells,  or  they  washed  contami- 
nated clothing  in  streams  which  were  used  for 
drinking  purposes.  In  this  way  the  germ  of 
cholera  gains  access  to  an  individual  and  spreads 
the  disease.  These  comma  bacilli  enter  the  in- 
testinal canal  and  increase  there  with  great 
rapidity,  and  when  passed  from  the  body  they 
live  and  thrive  in  the  presence  of  moisture. 
The  bacilli  do  not  invade  the  blood  or  organs 
of  the  patient.  Of  course,  only  those  predisposed 
to  the  disease  are  attacked.  Fright  and  fatigue, 
as  in  many  diseases,  are  important  factors  in 
the  causation  of  cholera.  It  attacks  by  prefer- 
ence those  who  suffer  from  diarrhoeal  diseases. 

Epidemics  of  cholera  occur  so  quickly, 
kill  so  suddenly,  and  create  so  much  general 
consternation,  that  the  principal  treatment  is  to 
protect  the  well  and  do  what  is  possible  for 
the  sick.  "  In  time  of  peace  prepare  for  war " 
is  a  motto  which  should  be  remembered  in  all 
such  diseases.  When  a  violent  conflagration 


9o  HYGIENE   OF  THE  SICK-ROOM. 


starts  in  a  village  not  properly  protected,  the 
inhabitants  are  either  hopeless  and  helpless,  or 
they  confine  their  efforts  to  protecting  the  un- 
burnt  district,  letting  the  burning  buildings  be 
destroyed,  until  the  fire  has  burned  itself  out. 
In  the  Eastern  countries  the  same  plan  was  fol- 
lowed with  respect  to  cholera.  The  whole  prin- 
ciple of  treatment  is  to  destroy  the  disease  and 
limit  its  action.  This  method  forms  the  basis  of 
our  international  quarantine  system,  about  which 
so  much  has  been  written.  In  spite  of  all  these 
quarantine  restrictions,  however,  the  disease  is  apt 
to  get  through.  The  theory  is  to  kill  the  comma 
bacillus  and  prevent  its  further  growth.  Quar- 
antine by  sea  can  be  carried  out  rather  effect- 
ually where  political  influences  do  not  interfere, 
but  quarantine  by  land  by  means  of  cordons  is 
of  little  avail. 

In  the  care  of  the  sick,  the  dejecta  and  the 
vomited  matter  should  be  received  into  a  vessel 
containing  a  carbolic  acid  solution  (i  :  20),  stirred 
up  thoroughly,  allowed  to  stand,  and  should  then 
be  emptied  into  a  pit  containing  unslaked  lime  and 
covered  by  the  same  material.  The  vessels,  cloth- 


ASIATIC  CHOLERA.  91 


ing,  etc.,  of  the  patient  should  be  boiled  in  a  car- 
bolic acid  solution  (i  :  20)  for  an  hour  or  more, 
while  the  body  of  the  patient  and  hands  of  the 
attendants  should  be  washed  in  a  bichloride  of 
mercury  solution  (i  :  1000).  Healthy  persons 
should  be  kept  as  far  as  possible  away  from 
the  sick,  all  errors  of  diet  should  be  guarded 
against  by  properly  selected  food  and  drink,  and 
the  strictest  hygiene  should  be  observed,  and  all 
excesses  should  be  avoided.  All  water  should  be 
boiled  and  filtered  before  using,  and  the  milk 
should  be  sterilized.  Diarrhcea  should  receive 
immediate  medical  attention.  In  case  of  death 
from  cholera,  all  the  clothes  should  be  burned, 
and  it  is  just  in  such  cases  as  this  that  cremation 
of  the  human  body  would  be  desirable.  The 
rooms  should  be  thoroughly  disinfected  for  hours 
with  fumes  of  sulphur  or  chlorine  gas,  and,  if  pos- 
sible, everything  that  came  in  contact  with  the 
patient  and  could  not  be  destroyed  by  burning 
should  be  exposed  to  prolonged  dry  heat,  or  to 
steam  at  212°  F.,  experiments  having  shown  that 
while  the  comma  bacillus  may  live,  thrive,  and 
multiply  in  moist  places,  it  soon  dies  when  dried. 


92  HYGIENE   OF  THE  SICK-ROOM. 

It  may  happen  that  cholera  will  not  appear 
again  as  an  epidemic  in  America  or  in  England, 
where  cleanliness,  the  great  protector  against  all 
diseases,  is  so  universal  as  compared  with  other 
countries,  but  in  case  of  sporadic  or  scattered 
cases  intelligent  supervision  should  be  peremp- 
tory and  immediate,  and  if  the  disease  should 
spread  military  discipline  is  necessary. 


CHAPTER  VII. 

SCARLET  FEVER  OR  SCARLATINA. 

In  the  early  part  of  the  sixteenth  century  the 
two  diseases,  measles  and  scarlet  fever,  could  not 
be  differentiated.  Now  there  are  few  good  nurses 
or  experienced  mothers  who  cannot  distinguish 
typical  cases  of  the  two  diseases  after  the  eruption 
has  appeared.  What  the  specific  micro-organism 
is  that  causes  scarlet  fever  is  not  certain.  Several 
investigators  have  described  what  they  thought 
was  the  germ,  but  as  yet  that  point  is  unsettled. 

However,  believing,  as  we  do,  that  every  infect- 
ious disease  has  a  distinct  cause  in  a  minute  organ- 
ism, we  accept  the  existence  of  an  as  yet  undiscov- 
ered germ  of  scarlet  fever,  arguing  from  the  history 
of  the  disease.  Like  many  other  organisms,  it 
probably  enters  the  system  by  the  breath,  but  it 
may  also  enter  with  the  food  taken.  It  is  certain 
that  the  poison  of  the  disease  infects  the  blood. 
This  has  been  proved  by  inoculating  with  the 
blood  of  a  patient  and  causing  the  disease.  The 
93 


94  HYGIENE   OF  THE  SICK-ROOM. 

breath  of  the  patient,  the  saliva,  the  secretions  of 
the  pharynx,  mucous  membranes,  the  epidermis 
scales,  the  evacuations  of  the  bladder  and  intestines 
all  may  contain  the  poison  of  the  disease,  and  in 
case  of  running  at  the  ear — a  not  uncommon  ac- 
companiment of  scarlet  fever — this  running  or  pus 
may  contain  the  disease  poison. 

Scarlet  fever  may  be  communicated  by  direct 
exposure  to  objects  which  are  in  the  room  during 
the  illness,  and  to  which  the  poison  becomes  at- 
tached, such  as  clothing,  books,  toys,  etc.  Trunks 
and  packages  containing  infectious  material  may 
carry  the  poison  to  a  distance.  The  clothing, 
books,  and  toys  belonging  to  a  child  who  has  died 
of  scarlet  fever  retain  the  poison  indefinitely.  This 
is  particularly  true  when  the  mother,  loath  to  part 
with  the  property  of  her  dead  child,  puts  them  into 
a  trunk  or  drawer,  where  they  may  lie  undisturbed 
and  harmless  until,  in  after  years,  she  takes  them 
out  and  gives  them  away,  or  uses  them  on  other  of 
her  children.  This  procedure  is  very  often  fol- 
lowed by  scarlet  fever  wherever  these  objects  go. 
In  its  tenacious  attachment  to  objects  and  its  port- 
ability to  distant  localities  this  poison  surpasses  in 


SCARLET  FEVER    OR  SCARLATINA.        95 

endurance  and  virulence  that  of  any  other  eruptive 
disease,  even  of  small-pox. 

Milk,  which  contains  everything  in  solution 
necessary  for  the  nutrition  of  all  persons,  particu- 
larly of  infants  and  young  children,  is  especially 
dangerous  on  account  of  the  risk  of  its  carrying 
disease.  Containing,  as  it  does,  so  much  nutriment, 
it  forms  an  excellent  medium  for  the  life  and 
growth  of  micro-organisms,  and  this  seems  to  be 
true  of  the  scarlet  fever  germ.  Again  and  again 
have  cases  occurred  which  have  been  traced  through 
the  infected  milk  to  the  first  case.  The  milk  sup- 
ply of  the  sick  and  the  young  cannot  be  too  strictly 
watched. 

The  public  schools,  and,  in  fact,  all  schools  where 
children,  and  especially  children  of  the  poorer 
classes,  congregate,  are  very  effective  disseminators 
of  the  disease.  In  large  cities  the  health  boards 
are  very  particular  about  preventing  children  who 
live  in  houses  where  there  is  or  has  been  scarlet 
fever  from  attending  school.  Laundresses  have 
been  known  to  spread  the  disease  by  mixing  the 
clothes  of  infected  people  with  other  clothes. 
Physicians,  hardened  to  exposure  and  too  fre- 


96  HYGIENE   OF   THE  SICK-ROOM. 

quently  thoughtless  to  true  danger,  are  often  very 
careless  about  how  they  pass  from  a  scarlet  fever 
case  to  a  healthy  child  or  a  patient.  Books  in 
libraries  and  the  public  schools  have  been  blamed, 
and  justly,  too,  for  spreading  the  disease. 

In  the  presence  of  a  perspn  ill  with  scarlet 
fever  the  area  of  contagion  is  small,  only  a  few 
feet;  therefore,  many  who  are  exposed  to  the 
disease,  and  who  are  careful  not  to  come  in  con- 
tact with  the  patient,  bed,  or  objects,  are  not  apt 
to  contract  it.  Indeed,  there  are  many  persons 
who  suffer  no  risk  by  coming  close  to  scarlet 
fever  patients,  for  they  touch  and  handle  the 
cases  with  perfect  impunity.  Still,  such  risks  are 
not  often  necessary,  and  nurses,  and  even  physi- 
cians, who  are  attending  scarlet  fever,  diphtheria, 
and  patients  sick  with  other  such  contagious 
diseases  should  touch  the  patient  only  when  ab- 
solutely imperative,  and  in  bringing  the  face  and 
mouth  close  to  such  patients,  if  such  a  thing 
should  ever  be  called  for,  the  mouth  and  nose 
should  be  covered  and  the  breath  held.  Such 
precautions  may  seem  foolish,  but,  considering 
the  dangerous  complications  of  these  contagious 


SCARLET  FEVER   OR  SCARLATINA.        97 

diseases,  too  much  care  cannot  be  taken,  and  the 
physician  or  nurse  who  is  negligent  in  these 
respects  is  guilty  of  criminal  neglect. 

We  have  undoubtedly  a  surgical  and  an  obstet- 
rical scarlet  fever.  That  is,  among  the  numerous 
germs  which  may  find  a  suitable  nest  on  a  fresh 
surgical  wound  or  an  abrasion  is  the  scarlet  fever 
germ.  Entering  into  an  exposed  wound,  it  may 
cause  genuine  fever,  even  in  the  adult.  The 
lying-in-woman,  too,  is  not  safe  from  this  source 
of  danger;  the  abraded  surfaces  of  the  genital 
tract  offer  a  good  breeding  place  for  the  scar- 
latinal germ,  and  the  disease  may  be  the  re- 
sult. Most  large  cities  have  boards  of  health, 
whose  duty,  among  other  things,  is  to  inves- 
tigate every  case  of  contagious  and  infectious 
disease  with  a  view  to  preventing  its  further 
spread.  However  capable  the  health  officers 
in  these  positions  may  be,  it  is  well  known  that 
many  of  their  sanitary  inspectors  are  simply  pro- 
fessional politicians  with  no  idea  of  their  duty. 

Dr.  J.  Lewis  Smith,  in  his  work  on  "  Diseases 
of  Children,"  states  that  "  The  New  York  Board 
of  Health  enforces  the  following  regulations  to  pre- 


98  HYGIENE  OF   THE  SICK-ROOM. 

vent  the  spread  of  scarlet  fever  as  well  as  other 
acute  infectious  maladies  : — 

"  Care  of  Patients. — The  patient  should  be  placed 
in  a  separate  room,  and  no  person  except  the  phy- 
sician, nurse,  or  mother  allowed  to  enter  the  room 
or  to  touch  the  bedding  or  clothing  used  in  the 
sick-room  until  they  have  been  thoroughly  disin- 
fected. 

"Infected  Articles. — All  clothing,  bedding,  or 
other  articles  not  absolutely  necessary  for  the 
use  of  the  patient  should  be  removed  from  the 
sick-room.  Articles  used  about  the  patient,  such 
as  sheets,  pillow-cases,  blankets,  or  clothes,  must 
not  be  removed  from  the  sick-room  until  they 
have  been  disinfected  by  placing  them  in  a  tub 
with  the  following  disinfecting  fluid  :  eight  ounces 
of  sulphate  of  zinc,  one  ounce  of  carbolic  acid, 
three  gallons  of  water.  They  should  be  soaked 
in  this  fluid  for  at  least  an  hour,  and  then  placed 
in  boiling  water  for  washing. 

"A  piece  of  muslin  one  foot  square  should  be 
dipped  in  the  same  solution  and  suspended  in  the 
sick-room  constantly,  and  the  same  should  be 
done  in  the  hallway  adjoining  the  sick-room. 


SCARLET  FEVER   OR  SCARLATINA.        99 

"  All  vessels  used  for  receiving  the  discharges 
of  patients  should  have  some  of  the  same  disin- 
fecting fluid  constantly  therein,  and  immediately 
after  being  used  by  the  patient  should  be  emptied 
and  cleansed  with  boiling  water.  Water-closets 
and  privies  should  also  be  disinfected  daily  with 
the  same  fluid,  or  a  solution  of  chloride  of  iron, 
one  pound  to  a  gallon  of  water,  adding  one  or  two 
ounces  of  carbolic  acid. 

"  All  straw  beds  should  be  burned. 

"  It  is  advised  not  to  use  handkerchiefs  about 
the  patient,  but  rather  soft  rags  for  cleansing 
the  nostrils  and  mouth,  which  should  be  imme- 
diately thereafter  burned. 

"  The  ceilings  and  side-walls  of  a  sick-room  after 
removal  of  the  patient  should  be  thoroughly 
cleansed  and  lime-washed,  and  the  wood-work 
and  floor  thoroughly  scrubbed  with  soap  and 
water." 

If  these  rules  were  strictly  followed  the  number 
of  cases  of  scarlet  fever  would  annually  grow  less. 
Of  course,  the  duty  of  reporting  a  case  of  scarlet 
fever  rests  either  with  the  physician  or  the  house- 
holder. In  many  cases  neither  reports  the  case 


ioo  HYGIENE   OF  THE  SICK-ROOM. 

to  the  local  health  office,  and  probably  in  this  way 
the  disease  is  frequently  spread.  Again,  rooms 
are  so  rarely  properly  disinfected  after  a  case ; 
they  are  simply  given  a  superficial  cleaning  and, 
if  in  a  boarding  or  lodging  house,  re-rented. 

As  soon  as  a  case  of  scarlet  fever  is  recog- 
nized it  should  be  put  in  an  upper  room,  so  as 
to  be  beyond  the  other  members  of  the  house- 
hold. Then  all  articles  not  strictly  necessary  for 
the  patient,  all  hangings,  curtains,  rugs,  etct> 
should  be  removed.  Any  papers  or  books  which 
may  have  been  used  to  amuse  the  patient  should 
be  promptly  burned  at  the  conclusion.  The  room 
should  be  ventilated,  but  should  never  be  kept  too 
cool.  As  the  disease  poison  is  principally  in  the 
skin,  the  whole  surface  of  the  body  should  be 
constantly  kept  anointed  with  vaseline  rubbed  up 
with  a  little  carbolic  acid.  This  not  only  cools 
off  the  body  and  is  pleasant  to  the  patient,  but  it 
prevents  the  scales  of  the  skin  from  flying  about 
and  spreading  the  disease.  A  three  to  five  per 
cent,  solution  of  carbolic  acid  in  water  may  be 
kept  simmering  on  a  stove  or  over  a  lamp.  As 
the  great  danger  in  scarlet  fever  is  the  compli- 


SCARLET  FEVER   OR  SCARLATINA.       101 

cations,  and  particularly  the  kidney  complications, 
a  case  should  never  be  hurried  to  recovery,  but 
kept  in  the  room  and  in  bed  a  long  time ;  hence 
the  faithful  nurse  is  under  a  great  strain  for  weeks 
at  a  time.  She  should  take  daily  exercise  alone, 
avoiding  other  people,  and  keep  up  her  strength,  as 
too  much  fatigue  might  invite  an  attack  of  the  dis- 
ease in  one  who  had  not  had  it. 

Desquamation,  or  the  peeling  of  the  skin  and  the 
disappearance  of  the  eruption  may  take  place  any- 
where between  the  first  and  the  third  week.  It 
may  begin  even  earlier,  and  the  whole  process  is 
sometimes  very  slow.  It  is  during  this  period  that 
the  skin  should  be  kept  well  anointed,  to  prevent 
the  dried  scales  of  skin  from  flying  about  and 
spreading  the  poison. 

By  some  unfortunate  accident  the  laity,  by  that 
peculiar  process  that  gets  everything  wrong,  has 
learned  to  make  a  distinction  between  scarlet  fever 
and  scarlatina.  It  is  just  as  well  to  state  that  the 
former  term  is  English  and  the  latter  is  Latin  for 
the  same  condition.  It  is  falsely  understood  that 
scarlatina  is  a  light  form  of  scarlet  fever,  a  state- 
ment which  probably  had  its  foundation  in  some 


102  HYGIENE   OF  THE  SICK-ROOM. 


pseudo-philologist  thinking  that  the  two  final  syl- 
lables of  the  word  "scarlatina"  gave  it  a  diminutive 
sense,  and  hence  it  meant  a  light  attack  of  scarlet 
fever.  Such  an  erroneous  idea  is  unfortunate,  and 
even  dangerous,  in  that  it  tends  to  make  one  care- 
less of  the  light  cases,  when  in  reality  the  light 
cases  may  have  the  worst  complications  if  not  kept 
in,  and  if  allowed  to  go  about  may  spread  the  dis- 
ease, it  being  well  known  that  light  cases  can  cause 
the  most  severe  ones,  and  vice  versa.  Hence  it  is 
always  better  to  err  on  the  right  side,  and  if  the 
case  be  doubtful  and  it  looks  like  scarlet  fever,  it  is 
better  to  treat  it  as  such  and  use  all  precautions, 
than  to  be  lax  and  spread  the  disease. 

The  time  may  come  when  an  examination  of  the 
skin  or  of  the  secretions  of  the  patient  microscopi- 
cally will  tell  us  early  in  the  course  of  the  dis- 
ease the  exact  truth  whether  it  is  scarlet  fever  or 
not. 


CHAPTER  VIII. 

MEASLES. 

Measles  is  a  disease  rarely  absent  from  large 
cities,  and  is  of  itself  generally  without  danger, 
but  its  complications,  while  not  usually  so  severe 
as  those  of  scarlet  fever,  are  to  be  feared.  As  in 
most  eruptive  diseases,  the  eruption  appears  not 
only  on  the  skin,  but  may  affect  the  mucous  sur- 
faces of  the  body;  hence  the  mucous  membrane 
lining  the  mouth,  the  trachea,  and  the  lung  tubes 
may  become  sufficiently  inflamed  to  give  rise  to 
sore  throat,  bronchitis,  and  even  pneumonia.  The 
mucous  surfaces  lining  the  inner  side  of  the  eye- 
lids and  also  that  covering  the  eye  become 
inflamed.  These  are  the  most  common  complica- 
tions of  measles,  but  less  severe  ones  may  occur. 

As  the  nurse  is  rarely  called  on  to  make  a 
diagnosis,  the  exact  appearance  of  the  eruption 
need  not  be  described.  Mothers  and  others  of 
intelligence  are  soon  able  to  make  out  a  case  of 
measles  from  scarlet  fever  after  the  eruption  has 
103 


104          HYGIENE   OF   THE  SICK-ROOM. 

appeared,  especially  if  they  are  typical  cases. 
Occasionally,  when  the  circulation  of  the  blood  in 
the  patient  is  slow  and  there  is  some  internal 
inflammation,  due  either  to  bronchitis  or  to  pneu- 
monia, the  eruption  presents  a  dark  appearance, 
and  we  have  a  case  of  what  is  ordinarily  known  as 
"  black  measles."  This  may  be  explained  as 
follows  :  The  redness  of  the  eruption  is  depend- 
ent, of  course,  on  the  blood  flowing  in  each  little 
point  of  eruption.  Now,  if  the  circulation  is 
unimpeded  the  eruption  retains  its  natural  color, 
but  if  the  circulation  of  the  blood  in  the  whole 
body  be  slow  and  the  blood  move  sluggishly 
along  in  the  small  blood-vessels,  lack  of  aeration 
or  air  supply,  which  makes  red  blood,  causes  the 
blood  in  those  points  to  take  on  a  dark  hue,  and 
when  the  blood  moves  so  slowly  that  it  coagu- 
lates it  looks  entirely  black.  This  form  of 
measles  is  usually  fatal,  not  because  the  points 
of  eruption  are  black,  but  because  of  impeded 
circulation  and  general  weakened  constitution 
Therefore,  no  case  of  measles  should  be  made 
light  of,  and  while  children,  those  usually  having 
the  disease,  may  pass  through  the  disease  without 


MEASLES.  105 


medical  attendance,  still,  the  risk  is  great,  and  no 
case  should  go  on  without  the  attention  of  a 
physician. 

For  the  very  reason  that  measles  is  considered 
a  disease  without  danger  it  is  apt  to  spread,  while 
a  more  dreaded  disease,  such  as  scarlet  fever  or 
diphtheria,  whose  dangers  are  appreciated,  is  kept 
in  bounds.  While  the  specific  micro-organism  of 
measles  has  never  been  isolated,  it  is  considered 
to  belong  to  the  class  called  micrococci.  It  is 
highly  contagious  through  the  air  and  at  a  much 
greater  distance  than  scarlet  fever  or  diphtheria. 
It  is  communicated  by  the  breath  and  by  exhala- 
tions from  the  body.  As  so  many  diseases 
begin  in  the  same  way,  measles  is  not  usually 
recognized  until  the  eruption  has  appeared.  This 
is  generally  from  ten  to  fourteen  days  after  the 
patient  has  become  infected.  For  this  reason  it 
is  harder  to  trace  this  disease  than  other  diseases 
which  require  a  shorter  time  to  make  themselves 
known. 

A  case  of  measles  should  be  isolated  just  as 
carefully  as  a  case  of  scarlet  fever.  Children  in 
the  same  house  should  be  kept  from  the  patient, 


106  HYGIENE   OF  THE  SICK-ROOM. 

and  should  also  not  be  allowed  to  go  to  school. 
As  the  poison  is  undoubtedly  in  the  skin,  the 
whole  surface  of  the  body  should  be  anointed 
with  vaseline,  which  not  only  keeps  the  epithelial 
scales  from  flying  about,  but  allays  the  itching,  as 
in  scarlet  fever. 


CHAPTER  IX. 

DIPHTHERIA. 

Some  diseases  are  dangerous  because  the  nurse 
may  carry  them  to  others  with  whom  she  may 
come  in  contact;  other  diseases  are  particularly 
dangerous  to  the  nurse  herself,  but  the  risk  of  car- 
rying the  contagion  is  small.  Diphtheria  is  a 
disease  which  has  both  of  these  dangers.  The  nurse 
is  always  liable  to  catch  it  and  she  may  easily 
carry  it. 

Diphtheria,  like  many  other  diseases,  was  origi- 
nally unknown  in  America,  the  aborigines  suffering 
only  from  those  diseases  induced  by  change  in  the 
climate  incident  to  their  wild  life.  Having  once 
entered  this  country,  diphtheria  followed  civiliza- 
tion, and  it  has  occurred  so  often  epidemically  that 
bacteriologists,  suspecting  a  specific  cause,  have 
been  looking  for  the  germ  peculiar  to  it.  This 
germ,  or  bacillus,  has  been  pretty  well  recognized 
and  described,  but  our  practical  results  from  this 
discovery  are  not  great  as  yet. 
107 


io8  HYGIENE   OF  THE  SICK-ROOM. 

The  two  men  who  have  given  the  most  time  and 
attention  to  looking  for  this  bacillus  are  Klebs  and 
Loeffler,  hence  it  is  called  the  Klebs-Loeffler  bacil- 
lus, or  bacillus  diphtherias.  It  is  a  small  bacillus, 
possessing  no  independent  power  'of  motion;  it 
forms  no  spores  or  seeds,  but  is  itself  very  resis- 
tant, withstanding  for  a  long  time  drying  and  other 
influences  injurious  to  the  less  resistant  forms.  It 
lives  and  multiplies  readily  in  milk.  The  diphther- 
itic poison  is  a  most  peculiar  poison  to  the  cells  of 
the  human  body,  producing  areas  of  cell  death  not 
only  on  the  surface  of  mucous  membranes,  but  also 
in  the  deeper  parts,  in  various  lymphatic  glands  at 
a  distance  from  the  local  lesion,  and  in  the  spleen. 

The  discovery  of  the  diphtheria  bacillus  is  only 
one  new  fact  in  the  germ  history  of  disease.  It  is 
now  pretty  well  settled  that  diphtheria  begins  as  a 
local  disease,  attacking  usually  the  mucous  surfaces 
of  the  throat  and  nose,  and  by  the  formation  of  a 
membrane  undermining  the  tissues  in  this  region 
and  poisoning  the  whole  system.  Like  many  other 
germs,  the  germ  of  diphtheria  is  in  itself  not  so 
harmful,  but  it  secretes  from  its  minute  body  a  vio- 
lent poison  which  enters  the  system  at  the  point  of 


DIPHTHERIA,  109 


contact,  which  is  usually  in  the  throat  or  nose,  and 
causes  those  extremely  dangerous  symptoms  of 
poisoning  and  paralysis  with  which  many  a  mother 
and  nurse  is  so  familiar.  Unfortunately,  it  is  prob- 
able that  when  once  the  disease  has  been  recog- 
nized in  a  given  case  the  specific  poison  has  in- 
vaded the  whole  body,  so  that  nothing  can  be  done 
but  try  to  sustain  the  patient  and  keep  the  disease 
from  spreading  to  others.  It  is  just  here  that 
modern  medical  chemistry  has  a  large  field  for  in- 
vestigation, to  study  these  dangerous  poisons  and 
furnish  us  with  trustworthy  and  easily  applicable 
antidotes  which  shall  counteract  the  poison  in  the 
body  without  harming  the  patient. 

Just  now  the  only  thing  to  be  done  is  to  keep 
up  the  system,  treat  the  local  parts  attacked,  and 
try  to  prevent  the  spread  of  the  disease  to  others 
in  the  house  or  neighborhood.  In  this  field  the 
good  nurse  or  intelligent  mother  has  a  great 
responsibility.  Some  cases  are  so  mild  that  they 
are  scarcely  recognized,  even  by  the  physician, 
and  it  is  just  those  mild  cases  that  do  the  most 
harm,  as  the  patient  may  go  about  and  spread  the 
disease  without  suspicion.  Diphtheria  is  so  con- 


i  io  HYGIENE   OF  THE  SICK-ROOM. 

tagious  that  a  moment's  exposure  to  the  breath 
of  a  patient  is  sufficient  to  cause  it  in  one  suscep- 
tible, or  to  be  in  the  infected  room  where  the 
patient  is  under  treatment,  or  even  has  been 
weeks  or  perhaps  months  previously,  has  in 
numberless  cases  caused  the  disease.  In  this  case, 
of  course,  the  breath  cannot  give  the  disease,  but 
it  can  contain  the  bacilli  attached  to  bits  of  secre- 
tion, etc.  This  is  true,  notwithstanding  the  fact 
that  the  area  of  contagion  of  this  disease  is  small, 
like  scarlet  fever,  as  contrasted  with  whooping 
cough  and  measles.  Damp,  ill-ventilated,  moist, 
and  mouldy  places  help  the  germs  to  flourish, 
but  are  never  of  themselves  sufficient  to  cause  the 
disease. 

The  germ  of  diphtheria  has  no  spores,  but  the 
germs  themselves  are  very  resistant  and  live  in 
spite  of  much  exposure.  They  withstand  pro- 
longed drying,  and  retain  their  vitality  in  rooms, 
clothing,  etc.,  for  months  and  longer.  Thus  a 
person  with  diphtheria  becomes  a  centre  of  infec- 
tion, endangering  those  near  by  and  the  whole 
locality.  Another  dangerous  element  is  the  fact  that 
animals,  particularly  members  of  the  feathered  tribe, 


DIPHTHERIA.  \  1 1 


often  have  the  disease ;  they  both  catch  it  from 
human  beings  and  give  it  to  them.  Cats  and  cows 
have  been  known  to  have  it,  and  with  the  latter  the 
danger  of  contagion  through  milk  is  very  great. 

It  is  sad  to  say  that  milk,  the  most  important 
article  of  nourishment  that  we  possess,  one  so 
largely  consumed  by  infants,  children,  and  invalids, 
is  a  very  good  medium  for  the  growth  of  many 
dangerous  germs  which  either  grow  well  or  live  a 
long  time  in  it.  In  order  to  prevent  the  spread  of 
the  disease,  preventive  measures  are  of  the  greatest 
importance.  There  is  one  element  of  encourage- 
ment in  all  this  danger,  namely,  that  unless  we 
come  into  very  close  contact  with  the  patient  the 
danger  of  catching  the  disease  is  not  great  in 
diphtheria  and  scarlet  fever, 'two  dangerous  dis- 
eases, as  it  is  in  whooping  cough  and  measles. 

The  bacillus  of  diphtheria  when  found  is  usually 
seen  in  the  upper  part  of  the  false  membranes  and  as 
bits  of  these  are  frequently  coughed  up  in  the 
course  of  the  disease,  herein  lies  the  chief  danger. 
This  coughing  is  the  more  dangerous  because  the 
nurse,  mother,  or  physician  has  so  frequently  the 
important  duty  of  making  applications  to  the 


112  HYGIENE   OF  THE  SICK-ROOM. 

throat,  and  in  her  zeal  the  nurse  or  mother  is  apt  to 
receive  some  of  the  expectoration  and  poison  in  her 
face  and  throat  from  the  patient,  who  spasmodically 
coughs  when  the  throat  is  sprayed  or  mopped. 

Dr.  William  H.  Welch,  of  the  Johns  Hopkins 
Hospital,  Baltimore,  has  made  a  careful  study  of 
diphtheria  and  the  Klebs-Loeffler  bacillus,  and  the 
following,  taken  from  an  article  of  his  on  account  of 
its  importance,  is  quoted  here  in  full.  He  says  : — 

"  From  what  has  already  been  said,  we  are  pre- 
pared to  consider  for  a  moment  in  what  ways  a 
person  affected  with  diphtheria  becomes  a  source 
of  danger  to  those  around  him  and  to  the  locality. 
The  diphtheritic  bacilli  are  conveyed  from  the  body 
in  particles  of  diphtheritic  exudation,  saliva  and  other 
secretions  discharged*  through  the  mouth  and  nose. 
(It  is  not  necessary  to  consider  here  the  compara- 
tively exceptional  localizations  of  the  disease.)  In 
this  way  the  infectious  substance  may  readily  be- 
come attached  to  the  person  and  clothing  of  the 
patient  and  of  those  around  him,  as  well  as  to  the 
bedding,  furniture,  floor  and  walls  of  the  room, 
dishes,  and  other  objects. 

"  Notwithstanding    the    statements    current    in 


DIPHTHERIA.  113 


nearly  all  the  text-books,  there  is  no  evidence  that 
the  breath  of  the  patient  contains  the  diphtheritic 
germ,  except  as  bits  of  false  membrane  or  secretion 
may  be  mechanically  expelled  in  the  act  of  cough- 
ing, hawking,  or  sneezing.  It  has  been  proven 
experimentally  that  the  expired  air  is  incapable, 
during  ordinary  respiration,  of  detaching  bacteria 
from  the  moist  mucous  surfaces  over  which  it 
passes.  The  specific  germs  are  not  so  readily  con- 
veyed by  air  currents  from  a  diphtheritic  patient 
to  those  near  him  as  they  are,  for  instance,  from 
a  patient  with  scarlet  fever,  in  which  the  germs 
are  in  all  probability  thrown  off  from  the  surface 
of  .the  body  on  light  epidermal  scales.  Nor  are 
the  chances  of  infection  of  the  sources  of  drinking- 
water  with  the  diphtheritic  bacillus  so  great  as  is 
the  case  with  such  diseases  as  cholera  and  typhoid 
fever,  in  which  the  stools  contain  in  large  number 
the  specific  bacteria,  and  are  likely  to  be  disposed 
of  in  such  a  way  that  under  bad  sanitary  condi- 
tions these  bacteria  may  find  their  way  into  wells 
and  streams.  While  there  are  some  accounts 
intended  to  show  the  conveyance  of  the  diphther- 
itic virus  through  the  drinking-water,  we  do  not 


114  HYGIENE   OF  THE  SICK-ROOM. 

hear  much  of  this  as  a  source  of  infection,  and  it  is 
not  likely  that  it  plays  an  important  role,  although 
it  is  probable  that  the  diphtheritic  bacillus  may 
sometimes  be  discharged  by  the  stools. 

"  Diphtheria  is  one  of  the  infectious  diseases 
the  germs  of  which  may  be  taken  into  the  body 
by  inspired  air.  Inasmuch  as  bacteria  cannot, 
under  ordinary  conditions,  occur  as  floating  mat- 
ter in  the  atmosphere  until  they  have  been  com- 
pletely dried  down  so  that  air  currents  can  detach 
as  dust  the  little  particles  to  which  they  adhere, 
it  is  evident  that  only  those  infectious  germs  are 
likely  to  be  conveyed  by  the  air  which  are  not 
destroyed  by  complete  drying.  As  has  already 
been  mentioned,  the  diphtheritic  bacillus  with- 
stands for  months  desiccation  which  is  so  injurious 
to  the  cholera  vibrio  and  to  many  other  species  of 
bacteria.  While,  therefore,  we  must  admit  that  air 
infection  with  the  diphtheritic  bacillus  is  a  real  and 
conspicuous  danger,  it  is  well  to  bear  in  mind 
that  modern  bacteriology  has  taught  us  the  great 
lesson  that  the  most  frequent  and  important  mode 
of  infection  is  by  contact  with  infected  substances. 
When  we  consider  the  manifold  ways  in  which 


DIPHTHERIA.  115 


the  diphtheritic  bacilli  may  be  widely  distributed, 
and  when  we  consider  the  habit  of  young  children 
— who  are  the  most  numerous  victims  of  the 
disease — of  handling  everything  and  of  putting 
everything  into  their  mouths,  we  are  led  to 
appreciate  that  infection  by.  contact  must  play 
the  leading  part  in  the  transmission  of  diphtheria. 
"A  matter  which,  although  not  new,  has 
attracted  much  attention  in  recent  years  may 
prove  to  be  of  such  importance  in  the  etiology 
of  diphtheria  that  I  will  direct  your  attention  to 
it  for  a  few  moments.  Evidence  has  been  brought 
forward  intended  to  show  that  diphtheria  may  be 
communicated  to  human  beings  by  domestic 
animals  afflicted  with  this  disease.  The  animals 
chiefly  concerned  are  cattle,  cats,  and  fowls. 
There  have  been  reported  in  England  during  the 
last  decade  epidemics  of  diphtheria  in  which  the 
evidence  is  strong  that  the  diphtheritic  germ  was 
conveyed  in  milk.  There  are  two  theories  as  to 
these  milk  epidemics.  One  is  that  the  diphthe- 
ritic virus  got  into  the  milk  from  persons  affected 
with  diphtheria,  the  other  is  that  the  cows 
yielding  the  milk  were  affected  with  diphtheria. 


ii6  HYGIENE   OF  THE  SICK-ROOM. 

This  second  daring  hypothesis  Klein  has  attempted 
to  support  by  experiment.  He  claims  that  by 
the  inoculation  of  two  cows  subcutaneously  on 
the  shoulder  with  a  broth  culture  of  the  bacillus 
diphtheriae  he  has  succeeded  in  producing  genuine 
infection,  with  the  ^appearance  of  vesicles  and 
pustules  on  the  udders  and  the  elimination  of 
the  specific  bacilli  in  the  milk.  These  experi- 
ments should  be  received  with  great  caution,  as 
they  are  in  opposition  to  all  that  we  know  con- 
cerning the  exclusively  local  development  of  the 
bacilli  at  the  point  of  inoculation.  We  possess 
no  satisfactory  evidence  that  cattle  are  ever 
affected  with  a  natural  disease  identical  etiologi- 
cally  with  human  diphtheria,  although  it  is  known 
that  an  affection  sometimes  called  diphtheria  may 
appear  in  calves. 

"  That  cats  may  acquire  diphtheria  and  may 
be  a  means  of  transmitting  the  disease  to  human 
beings  is  a  widely  spread  belief.  Medical  literature 
contains  many  instances  in  which,  on  the  one  hand, 
cats  appear  to  have  contracted  a  disease  by  eating 
substances  contaminated  with  the  discharges  from 
diphtheritic  persons ;  and,  on  the  other  hand, 


DIPHTHERIA.  117 


children  seem  to  have  become  infected  with  diph- 
theria by  handling  sick  cats.  Inasmuch  as  cats 
are  among  the  animals  most  susceptible  to  inocu- 
lation with  cultures  of  the  Loeffler  bacillus,  ac- 
quiring a  disease  resembling  human  diphtheria, 
there  is  no  a  priori  reason  that  they  may  not  be 
the  subjects  of  a  natural  disease  etiologically 
identical  with  diphtheria. 

"  But  the  possibility  of  the  experimental  pro- 
duction of  a  disease  in  an  animal  is  no  proof  of 
the  natural  occurrence  of  such  a  disease,  and  thus 
far  there  is  not  satisfactory  evidence  that  diph- 
theria occurs  as  a  natural  disease  in  cats.  What 
is  necessary  to  settle  the  question  is  to  make 
careful  bacteriological  studies  in  suspected  cases 
of  diphtheria  in  cats.  The  matter  is  of  sufficient 
interest  and  importance  to  merit  careful  study. 

"  Pigeons  also  are  susceptible  to  inoculation  with 
the  Loeffler  bacillus,  and  it  is  well  known  that 
a  membranous  inflammation  of  the  mouth,  fauces, 
and  trachea  occurs  as  a  destructive  epidemic  in 
chickens,  turkeys,  pigeons,  and  other  birds.  This 
so-called  diphtheria  of  fowls  has  not,  however, 
been  found  to  be  caused  by  the  same  micro-or- 


u8  HYGIENE   OF   THE  SICK-ROOM. 


ganism  which  causes  human  diphtheria,  so  that, 
notwithstanding  some  rather  striking  observa- 
tions according  to  which  human  beings  have 
appeared  to  contract  diphtheria  from  fowls,  there 
is  no  positive  proof  of  the  dissemination  of 
genuine  diphtheria  in  this  way.  It  may  be  that 
human  beings  may  become  infected  by  the  germs 
producing  the  so-called  diphtheria  in  domestic 
animals,  but  if  so  there  is  no  proof  that  the 
disease  produced  is  etiologically  identical  with 
the  disease  caused  by  the  Loeffler  bacillus. 

"  Inasmuch  as  the  diphtheritic  bacilli  are  pres- 
ent only  in  the  false  membranes  and  other  local 
products  of  the  disease  at  the  site  of  infection, 
and  are  distributed  outside  of  the  body  primarily 
through  these,  it  is  apparent  that  the  patient 
should  be  strictly  isolated ;  that  unnecessary 
fabrics  and  other  objects,  especially  such  as  can- 
not be  readily  disinfected,  should  be  first  removed 
from  the  room  where  the  patient  is  placed;  that 
care  should  be  taken  to  prevent,  as  far  as  possible, 
the  soiling  of  the  persons  and  clothing  of  the 
patient,  of  the  attendants,  and  of  the  physician, 
as  well  as  of  other  objects  in  the  room,  with 


DIPHTHERIA.  119 


the  discharges  of  the  patient;  that  opportunity 
should  not  be  afforded  for  the  desiccation  of  these 
discharges,  which  then  may  contaminate  the  air, 
and  that  efficient  measures  of  disinfection  of  the 
room  and  of  all  objects  which  by  any  possibility 
can  become  infected  should  be  employed. 

"  That  the  enforcement  of  measures  indicated  is 
capable  of  restraining  the  spread  of  the  disease, 
even  in  crowded  infants'  asylums  and  hospitals, 
has  already  been  demonstrated  by  actual  experi- 
ence. They  require  for  their  accomplishment 
education  on  the  part  of  the  community,  of  phy- 
sicians, and  of  sanitary  authorities  in  the  principles 
of  disinfection,  and  an  intelligent  appreciation  of 
the  dangers  to  be  guarded  against.  I  seize  this 
occasion,  as  I  have  others,  to  urge  the  importance 
in  cities  of  public  disinfecting  establishments  con- 
structed according  to  improved  modern  principles, 
and  of  a  corps  of  men  in  the  employment  of 
boards  of  public  health  trained  in  proper  methods 
of  disinfection. 

"  The  length  of  time  that  the  patient  should 
be  quarantined,  depends,  evidently,  upon  the  du- 
ration of  the  period  in  which  active  diphtheritic 


120          HYGIENE   OF   THE  SICK-ROOM. 

bacilli  remain  on  the  mucous  surfaces  attacked. 
As  to  this  point  we  possess  some  definite  informa- 
tion, which  shows  that  the  period  varies  within 
wide  limits.  In  some  cases  the  bacilli  can  no 
longer  be  found  after  the  false  membranes  have 
completely  disappeared  ;  in  many  cases  they  vanish 
within  three  or  four  days  after  the  local  inflamma- 
tion has  subsided,  but  they  have  been  found  as 
much  as  fourteen  days  after  the  inflammation 
has  gone,  and  when  the  mucous  membrane  ap- 
peared healthy.  In  a  case  reported  by  Loeffler, 
the  bacilli  were  found  three  weeks  after  the  return 
of  the  temperature  to  the  normal,  and  were  present 
for  a  month  altogether  in  a  state  capable  of  car- 
rying infection.  It  is  evidently  not  possible  to 
set  a  precise  limit  for  the  period  of  isolation  of 
the  patient.  Loeffler  suggests  that  the  patient 
should  not  be  permitted  to  mingle  with  others 
or  to  return  to  school  for  at  least  eight  days 
after  the  disappearance  of  all  local  manifestations, 
and  he  reckons  four  weeks  from  the  beginning 
of  the  disease  as  the  period  for  keeping  the  chil- 
dren out  of  school.  Where  it  is  possible  to  do 
so,  the  length  of  this  period  can  be  controlled 


DIPHTHERIA. 


by  bacteriological  examinations  of  the  mucous 
membrane  of  the  throat. 

"  We  have  thus  far  considered  the  patient  as 
the  immediate  source  of  infection.  The  evidence 
already  mentioned  in  favor  of  the  occasional  dis- 
semination of  the  diphtheritic  virus  through  the 
milk  suggests  at  once  the  importance  of  control- 
ling, not  only  the  condition  of  the  milk  as  received 
for  distribution,  but  also  of  inspecting  the  sources 
of  milk  supply.  Evidently  milk  should  not  be 
sold  from  dairies  attached  to  households  where 
there  are  cases  of  diphtheria. 

"  It  does  not  seem  to  me  permissible  to  throw 
out  altogether  the  possibility  of  the  conveyance  of 
diphtheria  by  domestic  animals,  especially  by  cats, 
which  are  likely  to  be  fondled  by  children  even 
more  when  the  animals  are  sick  than  when  they 
are  well. 

"  In  considering  what  can  be  done  to  render 
children  less  vulnerable  to  diphtheria,  and  to  ward 
off  an  attack  after  exposure  to  the  disease,  the 
question  arises,  what  conditions  of  the  individual 
we  may  regard  as  predisposing  causes.  Clinical 
experience,  as  well  as  experiments  upon  animals, 


122  HYGIENE   OF  THE  SICK-ROOM. 

indicate  that  morbid  states  of  the  mucous  mem- 
brane of  the  throat,  such  as  ordinary  catarrhal 
inflammations,  swollen  tonsils,  sensitiveness  to 
'  catching  cold,'  the  existence  of  measles  and  scar- 
let fever,  are  predisposing  factors.  At  all  times, 
but  especially  during  the  epidemic  prevalence  of 
diphtheria,  it  is  important  to  hold  in  check  these 
morbid  states  as  far  as  possible. 

"  The  prophylactic  value,  in  persons  liable  to  ex- 
posure to  diphtheria,  of  cleanliness  of  the  teeth 
and  mouth,  and  of  the  frequent  use  of  weak  anti- 
septic mouth-washes,  nasal  douches,  and  gargles  is 
worthy  of  the  attention  of  physicians.  For  this 
purpose  Loeffler  recommends  aromatic  waters, 
weak  sublimate  solutions  (i  :  10,000  to  I  :  15,000), 
or,  perhaps  better,  solutions  of  mercuric  cyanide 
(1:8000  to  i  :  10,000);  also,  chloroform  water, 
chlorine  water  (i  :  iioo),  thymol  (i  :  500  parts  of 
twenty  per  cent,  alcohol).  The  use  of  some  of 
these  solutions  evidently  involves  danger  of  pois- 
oning in  children  unless  special  precautions  are 
taken. 

"  The  suggestion  recently  made  by  Dr.  Jacobi, 
that,  in  addition  to  caring  for  those  sick  with  diph- 


DIPHTHERIA.  123 


theria,  places  of  refuge  should  be  provided  for  the 
temporary  stay  of  children  sent  from  home  to  es- 
cape infection,  seems  practical  and  calculated  to 
meet  the  circumstances  of  many  families. 

"The  dominant  role  played  by  schools  in  the 
spread  of  diphtheria  throughout  a  community  ren- 
ders especially  urgent  the  introduction  of  a  system 
of  daily  medical  inspection  of  the  schools. 

"  The  importance  of  letting  air  and  sunlight  into 
dark,  damp  dwellings,  and  of  attending  in  general 
to  matters  of  domestic  sanitation,  is  a  lesson 
plainly  to  be  drawn  from  the  history  of  such  places 
as  nests  of  diphtheria." 

One  of  the  most  important  preventive  measures 
after  diphtheria  is  a  thorough  disinfection  of  the 
room  occupied  by  the  patient.  Dr.  J.  Lewis 
Smith,  of  New  York,  thinking  the  method  of 
disinfection  by  burning  sulphur  in  a  closed  room 
for  several  hours  was  questionable  or  inadequate, 
experimented  with  it  in  a  ward  in  the  New  York 
Infant  Asylum  in  which  there  had  been  an  epi- 
demic of  diphtheria.  This  ward  was  emptied, 
"  the  windows,  doors,  and  crevices  closed,  and 
forty  pounds  of  sulphur,  or  two  pounds  to  the 


124  HYGIENE   OF  THE  SICK-ROOM. 


hundred  cubic  feet  of  air,  were  burnt  until  they 
were  consumed."  After  several  hours  the  doors 
were  opened  and  dust  from  the  floor,  bedding, 
and  furniture  was  stirred  up  and  allowed  to 
settle  on  culture  media  which  had  been  pre- 
pared for  the  experiment.  The  result  was  that 
there  were  found  on  the  culture  media  many  forms 
of  micro-organisms  which  had  been  in  the  room 
before  the  sulphur  was  burned. 

As  this  mode  of  disinfection  seemed  far  from 
perfect,  Dr.  Smith  wrote  to  E.  R.  Squibb,  of 
Brooklyn,  and  obtained  the  following  reply : — 

"  Within  the  past  ten  years  the  efficacy  of 
sulphur-fumigation  against  infectious  material  has 
been  repeatedly  denied  and  reaffirmed  upon  very 
good  authority,  and  observations,  apparently  made 
with  accuracy  and  care,  have  been  reported  from 
time  to  time  to  prove  both  sides  of  the  question ; 
so  that  all  that  can  now  be  said  is  that  burning  sul- 
phur is  of  doubtful  efficacy,  with  the  weight  of  the 
highest  authorities  in  bacteriology  against  it.  But 
to  this  it  must  be  added  that  it  is  still  largely 
used  by  very  intelligent  bodies  in  large  insti- 
tutions, boards  of  health,  etc.,  where  it  would 


DIPHTHERIA.  125 


not  be  likely  long  to  maintain  an  universal  confi- 
dence. 

"  How  often  the  fumes  are  applied  dry  and  how 
often  moist  no  one  can  tell  from  the  current  record; 
and  how  many  of  the  failures  of  the  dry  gas  would 
be  successes  in  the  presence  of  moisture  there  is  no 
means  of  knowing. 

"  Formerly,  when  sulphur  was  burned  in  closed 
chambers  as  a  disinfectant,  the  surfaces  were  all 
wetted,  and  the  pot  of  burning  sulphur  was  set  in 
water  or  wet  sand,  that  the  heat  might  evaporate 
off  a  constant  supply  of  watery  vapor. 

"  These  conditions  are  now  frequently,  if  not 
generally,  neglected;  and  where  this  is  the  case, 
failure,  on  principle,  should  be  the  rule. 

"  Nearly  all,  if  not  all,  chemical  disinfectants  are 
in  a  state  of  tension,  ready  to  change  on  coming  in 
contact  with  the  matter  to  which  they  are  applica- 
ble ;  and  these  changes  are  either  by  oxidation  or 
deoxidation,  and  the  moment  of  greatest  power  or 
activity  is  the  moment  of  change,  when  they,  by 
reacting  on  infectious  matter,  pass  from  a  state  of 
tension  to  a  state  of  rest  under  new  relations. 
The  agency  through  which  these  changes  almost 


126  HYGIENE   OF   THE  SICK-ROOM. 

universally  become  operative  is  the  vapor  of 
water. 

"  When  sulphur  is  burned  in  a  close  chamber  the 
dioxide  is  formed  by  condensing  the  molecules  of 
oxygen  from  the  air  upon  each  molecule  of  the 
s-ulphur,  and  a  heavy  gas  is  the  result,  which 
tends  to  settle  at  the  bottom  of  the  chamber  and 
to  run  out  through  the  lower  cracks.  Any  mois- 
ture present  is  at  once  seized  by  this  rather  inactive 
anhydride,  first  forming  sulphurous  acid,  and  then, 
by  oxidation  from  the  air,  sulphuric  acid.  The  dry 
gas,  or  anhydride,  not  only  seizes  with  avidity  all 
watery  vapor  in  the  air,  but  also  the  water  held  in 
the  surfaces  of  all  bodies  with  which  it  comes 
in  contact,  and  in  the  presence  of  this  moisture 
only  is  it  ready  for  further  oxidation.  Then  it 
is  by  this  oxidation  that  it  deoxidizes  the  mat- 
ters with  which  it  is  in  moist  contact,  filling 
the  surfaces  of  these  matters  first  with  sulphu- 
rous acid,  then,  by  the  change,  with  sulphuric 
acid;  and  it  is  during  these  changes  that  its 
power  is  exerted. 

"  If  there  be  no  moisture  supplied  to  the  burning 
sulphur,  that  which  was  present  in  the  air  and  on* 


DIPHTHERIA.  127 


the  surfaces  of  the  chamber  is  soon  used  up,  and 
the  dry  gas  remains  indefinitely  in  a  compara- 
tively inactive,  ineffective  condition.  The  dry, 
passive  anhydride  would  necessarily  destroy  all 
organisms  which  breathed  in  any  degree,  because 
breathing  surfaces  are  moist.  But  in  embyronic 
life  protected  by  shell,  as  in  seed,  if  the  shell  be 
dry  the  gas  would  be  impotent.  Many  bacteri- 
ologists have  admitted  that  burning  sulphur  would 
kill  bacteria,  but  not  germs." 

This  is  quoted  in  full  because  it  is  important 
to  impress  the  fact  that  sulphur  to  be  effective 
should  be  burned  in  the  presence  of  enough 
moisture. 

Dr.  J.  Lewis  Smith  uses  the  following : — 

R     Carbolic  acid,  one  ounce 

Oil  of  eucalyptus,  one  ounce 

Spirits  of  turpentine,  eight  ounces. 

Mix  this  thoroughly  and  add  two  tablespoonfuls  to 
the  quart  of  water  in  a  pan  with  broad  surfaces, 
and  maintain  in  a  constant  state  of  ebullition 
or  simmering  in  the  room  occupied  by  the 
patient. 

Other  methods  have  been  proposed,  but  all  with 
the  same  object. 


CHAPTER  X. 

SMALL-POX. 

Small-pox  is  a  disease  which  prompt  vaccina- 
tion has  so  far  limited  in  this  country  that  epi- 
demics occur  at  longer  intervals  each  time.  It  is 
the  one  disease  which  can,  with  certainty,  be 
prevented.  That  vaccination,  properly  performed, 
.protects  for  a  varying  period  against  attacks  of 
small-pox  no  person  understanding  medicine  will 
deny.  It  is  a  disease  which,  when  once  occurring, 
should  be  treated  by  the  strictest  isolation. 

Even  if  the  theory  of  vaccination  has  never 
been  satisfactorily  explained,  its  practical  results 
are  so  clear  that  it  should  be  performed  on  all 
persons  indiscriminately ;  if  the  disease  be  recog- 
nized or  suspected  early  enough,  even  on  the 
patient  himself.  This  should  be  compulsory  by 
law,  as  it  is  in  some  places.  The  protective  power 
of  vaccination  shows  itself  in  a  few  days  if  it 
appears  at  all,  while  the  disease  itself,  when  once 
contracted,  takes  a  longer  time  to  develop. 
128 


SMALL-POX.  129 


Hence,  vaccination,  even  after  the  disease  has  set 
in,  mitigates  the  attack  and  shortens  the  disease. 
In  almost  all  well-regulated  cities  which  have  a 
health  officer  there  is  a  corps  of  vaccine  physicians, 
whose  duty  it  is  to  vaccinate  the  unvaccinated  as 
often  as  they  may  think  proper,  to  inspect  all 
vaccination  marks,  and  to  give  certificates  to  all 
school-children  before  the  opening  of  each  session. 
Theoretically,  this  would  effectually  stamp  out 
small-pox  if  this  method  were  carried  out  so  strictly. 
Practically,  such  strict  supervision  only  obtains 
after  small-pox  has  broken  out  or  after  a  scare  of 
the  disease. 

Cases  that  do  occur  are  usually  brought  in  by 
emigrant  ships — which,  indeed,  are  at  the  bottom 
of  much  of  the  poverty,  misery,  and  disease  in 
the  United  States. 

Dr.  J.  Lewis  Smith  says:  —  "Small-pox  is  so 
very  contagious  that  there  is  danger  that  the 
physician  and  attendant  may  communicate  it 
through  their  persons  or  clothing.  The  virus 
adheres  tenaciously  to  objects,  and  may  be  con- 
veyed by  them  long  distances." 

All  unnecessary  objects  should  be  removed  from 


130  HYGIENE   OF  THE  SICK-ROOM. 

the  room  and  disinfectants  should  be  thoroughly 
used.  While  small-pox  has  some  very  undesirable 
complications,  they  are  by  no  means  so  dangerous 
as  those  following  scarlet  fever.  As  an  offset  to 
this,  the  disease  itself  is  much  more  to  be  dreaded; 
it  is  so  severe  and  its  mortality  is  so  great.  As 
in  measles,  there  is  a  black  variety  of  small-pox, 
and  there  are  other  varieties  which  are  very  fatal. 
Aside  from  the  dangers  of  great  mortality,  the 
nurse  should  never  forget  the  terrible  disfigure- 
ments that  may  and  often  do  follow  an  attack  of 
small-pox.  She  should  follow  the  physician's 
directions  with  military  precision  and  particularly 
use  faithfully  any  means  to  prevent  the  "  pitting," 
which  is,  after  all,  the  worst  result  of  small-pox. 

The  scientific  name  for  small-pox  is  variola.  If 
the  patient  have  been  vaccinated  at  some  period  in 
his  life,  the  disease,  which  is  rendered  milder  in 
consequence,  is  called  varioloid ;  that  is,  resem- 
bling variola.  It  is  much  like  variola  or  small-pox, 
and  is  chiefly  dangerous  because  it  causes  genuine 
small-pox  in  one  not  vaccinated  and  predisposed. 
In  fact,  each  disease  can  communicate  the  other. 


CHAPTER  XL 

YELLOW  FEVER. 

Yellow  fever  is  another  of  the  preventable  filth 
diseases.  It  has  been  considered  by  some  as  a 
miasmatic-contagious  disease,  but  a  more  careful 
study  seems  to  have  separated  it  from  the  malarious 
diseases.  The  specific  organism  of  this  malady 
has  not  yet  been  found,  although  much  work  on  the 
subject  has  been  done.  Jhere  is  some  reason  to 
believe  that  it  is  caused  by  a  germ  whose  habitat 
is  in  the  intestines.  The  disease  is  found  princi- 
pally in  the  tropical  regions  and  rarely  where  the 
temperature  is  below  70°  F.  Its  period  of  incuba- 
tion is  from  one  to  fourteen  days,  and  its  onset  is 
often  very  sudden  and  its  mortality  very  high. 

Overcrowding  and  the  presence  of  filth,  such  as 
the  accumulation  of  excreta  around  dwellings,  are 
the  most  usual  predisposing  causes.  It  is  particu- 
larly prevalent  on  shipboard  and  in  seaports,  and 
is  very  apt  to  break  out  on  an  infected  ship  as  soon 
as  it  lands.  As  soon  as  the  temperature  gets  below 


132  HYGIENE   OF  THE  SICK-ROOM. 

70°  F.  the  disease  begins  to  disappear,  and  usually 
the  first  frost  puts  a  stop  to  the  disease.  One  at- 
tack generally,  but  not  always,  protects  against  fu- 
ture attacks  of  the  disease.  The  negro  race  is  al- 
most exempt  from  the  disease.  Occupation,  filthy 
surroundings,  fatigue,  dissipation,  any  excesses, 
and,  it  is  said,  fear,  all.  invite  the  disease.  It  is  epi- 
demic in  warm  countries  and  may  be  carried  by 
the  air,  but  the  intervention  of  a  high  wall  or  a 
stream  has  been  known  to  cut  off  its  march. 

Persons  who  live  among  the  sick  and  are  used  to 
the  climate  are  not  so  apt  to  contract  the  disease  as 
the  fresh  arrivals  who  are  not  acclimated.  The 
prophylactic  treatment  is  very  important.  The 
strictest  quarantine  should  be  enforced,  although 
its  power  of  preventing  the  disease  has  been  called 
in  question.  The  occasional  outbreaks  occurring  in 
the  southern  parts  of  the  United  States  have  in 
every  case  been  due  to  the  collection  of  filth  and 
dirt.  Careful  quarantine,  pure  drinking  water, 
good  sewerage  and  ventilation,  and  supporting 
treatment  will  do  much  toward  removing  the 
disease. 


CHAPTER  XII. 

EPIDEMIC  INFLUENZA. 

Epidemic  influenza,  or  more  commonly  called 
the  grip,  from  the  French  "  grippe,"  is  a  disease 
which  has  become  painfully  familiar  to  a  large  part 
of  the  civilized  world.  It  has  aroused  such  univer- 
sal interest  and  consternation  that  a  few  words 
about  it  may  not  be  out  of  place  in  this  work. 
It  assumes  so  many  forms  and  appears  in  so 
many  disguises  that  an  exact  description  of  the 
disease  is  not  easy.  It  appears  so  suddenly  and 
seems  to  attack  so  quickly  that  the  Germans  call 
it  "  Blitzkatarrh,"  or  lightning  catarrh,  because  it 
seems  to  strike  like  lightning. 

The  most  prominent  symptoms  are  high  fever, 
marked  prostration,  generally  dry  cough,  and  severe 
pains  in  the  back,  limbs,  and  head,  especially  across 
the  forehead.  The  disease  usually  lasts  a  short 
time,  and  if  there  are  no  complications  recovery  is 
not  slow,  but,  unfortunately,  the  convalescence  is 
the  worst  part,  the  patient  often  continuing  to  be 
133 


I34  HYGIENE   OF  THE  SICK-ROOM. 

under  the  influence  of  the  poison  for  weeks, 
months,  and  even  longer.  The  most  dangerous 
complication  is  pneumonia,  which  seems  to  follow 
this  trouble  in  weakened  individuals  with  remark- 
able frequency. 

Epidemic  influenza  has  been  familiar  to  physi- 
cians for  fifty  years  or  more,  but  the  more  recent 
epidemics,  occurring  in  the  past  few  years,  have 
given  not  only  physicians,  but  also  laymen,  a  very 
undesirable  experience  with  this  disease.  It 
usually  begins  in  Russia  and  sweeps  across  the 
continent  and  ocean  in  a  few  weeks,  often  in 
opposition  to  winds.  As  the  more  recent  attacks 
have  occurred  since  our  greater  familiarity  with  bac- 
teriology, it  was  natural  that  the  first  announce- 
ment of  the  reappearance  of  this  disease  should 
have  set  bacteriologists  and  would-be  bacteriologists 
to  look  for  the  specific  organism,  and  many  were 
the  reported  discoveries  which  were  published  in 
the  daily  press,  which  at  the  present  day  seems  to 
be  the  disseminator  of  our  knowledge  of  medicine. 

Many  discoveries  of  the  specific  organism  of  this 
disease  have  been  announced,  but  it  is  doubt- 
ful if  any  of  them  are  of  value.  Unsanitary  sur- 


EPIDEMIC  INFLUENZA.  135 


roundings  and  damp  weather  with  heavy  fogs  favor 
the  spread  of  the  influenza.  It  is  probably  a  mias- 
matic disease,  like  malaria.  Little  can  be  done  by 
the  nurse  to  prevent  the  spread  of  the  disease.  It 
has  been  said  to  be  contagious,  and  with  this  idea 
some  physicians  have  isolated  with  alleged  good 
results  their  cases.  Any  attempt  to  destroy  the 
as  yet  undiscovered  germ  of  this  disease  is  prob- 
ably of  no  use,  and  hence  no  especial  precautions 
are  needed ;  that  is,  considering  the  disease  with 
our  present  knowledge. 


CHAPTER  XIII. 

PNEUMONIA. 

Although  pneumonia  can  hardly  be  classed 
among  the  preventable  diseases,  still,  it  probably 
belongs  to  those  diseases  whose  cause  is  a  micro- 
organism. It  can  hardly  be  said  to  be  contagious, 
but  where  a  number  of  cases  occur  in  the  same 
place  and  about  the  same  time  it  is  very  likely 
that  the  cause  is  the  same.  It  was  at  one  time 
looked  upon  as  a  simple  inflammation  of  the  lung 
substance,  but  recent  bacteriological  studies  have 
detected  the  presence  of  certain  organisms  which 
are  usually  absent  where  there  is  no  pneumonia. 

The  organism  most  generally  agreed  upon  as 
standing  in  causal  relation  to  the  ordinary  acute 
pneumonia  is  described  as  a  diplococcus,  that  is,  it 
is  two  round  cocci  apparently  joined  together. 
This  organism  has  been  found  in  the  sputum 
of  those  sick  with  pneumonia,  and  its  almost 
constant  presence  in  this  disease  is  very  strong 
evidence  that  it  is  the  specific  organism  of  pneu- 
136 


PNEUMONIA.  137 


monia.  Unfortunately,  we  are  not  able  to  repro- 
duce the  disease  in  animals  in  a  manner  to  make 
the  chain  of  evidence  complete.  When  the  sputum 
from  a  pneumonic  patient  is  inoculated  under  the 
skin  of  a  rabbit,  the  animal  sickens  and  dies  in  a 
few  days,  and  the  blood  is  found  to  contain  an 
almost  pure  culture  of  these  diplococci,  but  the 
same  experiments  with  dogs  and  some  other 
animals  have  not  been  so  successful. 

Epidemics  of  pneumonia  have  occurred  and  been 
reported  from  time  to  time  in  which  the  disease, 
according  to  the  history  given,  seems  to  have 
been  transmitted  by  contagion,  but  this  cannot 
be  absolutely  proved.  There  is  one  significant 
fact  connected  with  this  disease  which  would 
seem  to  point  to  the  presence  of  a.f  specific  or- 
ganism, and  that  is  that  sailors  far  out  at  sea 
and  exposed  to  the  severest  weather  rarely  have 
pneumonia,  while  rheumatism  is  not  an  uncommon 
disease  with  them,  which  might  look  as  if  the 
pneumonia  organism  did  not  thrive  at  sea — a 
place  where  notably  few  germs  live  and  thrive — 
and  that  a  pneumonia  was  something  more  than 
an  ordinary  inflammation  of  the  lungs. 


138  HYGIENE   OF  THE  SICK-ROOM. 

Precautions  are  rarely  taken  to  prevent  the 
spread  of  this  disease,  and  this  is  very  natural, 
too,  for  experiment  has  shown  that  this  very 
diplococcus  of  pneumonia  is  very  often  found  in 
the  sputum  of  apparently  healthy  persons.  Still, 
the  sputum  of  pneumonic  patients  might  just 
as  well  be  disposed  of  in  a  careful  manner  as 
to  be  thrown  out  like  harmless  matter.  The 
sputum  cup  should  always  contain  a  one-to-one- 
thousand  bichloride  solution,  and  the  cup  should 
be  cleaned  frequently,  especially  if  the  sputum 
has  a  dark  or  reddish-brown  color,  due,  in  part, 
to  the  presence  of  blood.  No  especial  attempts 
at  isolation  are  necessary.  It  might  be  added 
that  the  sputum  of  pneumonic  patients  contains 
this  diplococcus  long  after  the  disease  has  dis- 
appeared and  the  patient  is  entirely  well. 


CHAPTER  XIV. 

WHOOPING  COUGH.     PERTUSSIS. 

Whooping  cough  is  a  communicable  disease 
depending  on  a  specific  poison  and  prevailing  epi- 
demically or  sporadically.  It  is  highly  contagious. 
The  poison  seems  to  have  certain  periods  of  activity 
and  can  exist  outside  of  the  body.  When  intro- 
duced through  the  respiratory  canal,  it  produces 
those  well-known  symptoms  so  familiar  to  mothers, 
nurses,  and  many  others.  The  principal  and  dis- 
tinctive sign  is  the  whoop,  which  is  evidently  of  a 
nervous  origin.  The  period  of  incubation  is  about 
two  weeks,  and  the  poison  is  carried  from  one  child 
to  another,  principally  through  the  dried  sputa. 

Several  investigators  have  described  micro-organ- 
isms, but  none  of  them  are  distinctive,  and  the  true 
germ  of  pertussis  is  still  to  be  discovered.  Chil- 
dren with  pertussis  should  be  isolated,  their  ex- 
pectoration well  disinfected,  and  their  clothes,  which 
are  very  ready  carriers  of  the  disease,  should  be 
well  boiled  before  washing.  The  disease,  like  many 
139 


140  HYGIENE   OF  THE  SICK-ROOM. 

others,  is  dangerous  on  account  of  its  complications, 
hence  the  child  should  be  under  the  care  of  the 
physician. 


CHAPTER  XV. 

MALARIA. 

The  word  "  malaria  "  literally  means  "  bad  air." 
In  its  present  sense  it  comprises  intermittent,  re- 
mittent, and  continued  fever.  Whatever  causes 
malaria  is  very  elusive,  and  in  spite  of  much 
work  by  able  investigators  there  seems  to  be  doubt 
in  the  minds  of  some  if  the  organism  of  malaria 
has  ever  been  discovered. 

Like  most  diseases,  malaria  was  studied  by  its 
effects  and  by  certain  peculiarities  of  the  disease. 
It  is  a  disease  peculiar  to  low  lands,  to  marshy 
districts  where  there  is  much  water  in  a  comparative 
state  of  quiescence,  particularly  near  fresh  water,  or 
fresh  and  salt  water  mixed.  The  disease  does  not 
flourish  below  an  average  of  58°  F.  for  the  twenty- 
four  hours,  and  will  not  prevail  as  an  epidemic  un- 
less the  average  temperature  ranges  as  high  as  65° 
F.  for  the  twenty-four  hours;  It  seems  to  prevail 
particularly  where  there  has  been  much  digging  up 
of  the  soil.  Workmen  who  dig  up  our  city  streets 
141 


H2  HYGIENE   OF  THE  SICK-ROOM. 

on  the  slightest  provocation  meet  their  just  punish- 
ment in  this  disease.  The  hospital  and  dispensary 
records  show  an  increased  number  of  such  cases 
when  there  is  much  digging  up  of  the  streets. 

From  its  name  it  may  be  seen  that  it  was  studied 
first  in  Italy,  and  that  is  because  it  occurs  in  its 
worst  forms  in  parts  of  Italy.  Whatever  is  the 
cause  of  the  disease,  it  can  be  carried  by  rivers  to 
places  not  subject  to  it ;  it  can  be  carried  by  heavy 
winds  up  mountains  where  it  is  never  supposed  to 
occur.  In  this  way  an  outbreak  in  the  Catskill 
Mountains  one  summer  was  accounted  for.  It  has 
been  carried  for  a  short  distance  to  sea,  causing  an 
outbreak  on  vessels  near  land.  The  earliest  work 
on  the  causation  of  this  disease  was  done  on  the 
Pontine  Marshes  in  the  neighborhood  of  Rome. 
Persons  not  acclimated  who  remain  exposed  to  the 
air  of  the  Pontine  Marshes  usually  acquire  malaria, 
and  even  those  at  a  distance  from  the  Marshes 
when  the  wind  blows  without  obstruction  are  apt 
to  catch  this  disease. 

The  Italian  investigator  who  first  described  what 
he  thought  was  the  malarial  organism  was  Dr. 
Tommasi  Crudeli,  of  Rome.  He  had  observed  for 


MALARIA.  143 


years  large  numbers  of  cases  in  and  about  Rome, 
particularly  among  the  strangers ;  he  also  noticed 
the  extreme  prevalence  of  this  disease  when  the 
wind  blew  from  over  the  Marshes  to  Rome. 
Still  further,  he  noticed  that  when  trees  grew  be- 
tween the  Marshes  and  a  certain  locality  that  the 
disease  did  not  penetrate  and  infect  that  locality, 
that  is,  the  trees  seemed  to  act  the  part  of  a  filter 
and  free  the  air  from  this  unknown  cause  of  dis- 
ease. 

Tommasi  Crudeli  exposed  glass  plates  to  the  air 
of  malarious  districts  and  then  examined  the  cul- 
tures thus  obtained  microscopically.  Noticing  an 
organism  always  present,  he  described  this  as  the 
malaria  organism,  but  work  done  since  has  shown 
that  Crudeli  simply  described  some  ordinary  in- 
gredient of  the  air.  In  1882  Laveran,  a  French- 
man, while  serving  in  Algiers  had  opportunity  to 
see  large  numbers  of  cases  of  malaria,  and  he  made 
use  of  this  opportunity  by  studying  them.  His 
work  was  done  under  great  disadvantages  and  with 
many  hindrances,  for  he  had  very  imperfect  instru- 
ments and  crude  lenses  ;  still,  with  no  further  help 
he  carefully  studied  the  blood  of  the  sick,  and  his 


144  HYGIENE   OF  THE  SICK-ROOM. 

observations  recorded  at  that  time  were  so  well 
made  that  further  work  has  done  little  but  confirm 
his  efforts. 

Laveran  found  in  the  blood  an  organism  or  germ 
which  he  called  a  protozoon  or  plasmodium.  It 
assumes  different  shapes  at  different  times  and  at 
different  stages  of  the  disease,  is  found  either  free 
or  in  the  blood  corpuscles,  and  is  particularly  abun- 
dant during  a  paroxysm.  His  theory  was  that  this 
little  organism,  much  like  9.  parasite,  attacked  the 
red  blood  corpuscles,  deprived  them  of  their  red 
color,  which  is  their  life,  and  prevented  them  from 
doing  their  work.  The  use  of  quinine  causes  these 
organisms  to  disappear.  This  organism  is  now  ac- 
cepted as  the  cause  of  malaria,  and  its  diagnostic 
value  has  been  proved  to  the  satisfaction  of  clini- 
cians, but  the  life  history  of  the  organism  has  not 
yet  been  completely  studied,  as  it  does  not  grow  on 
the  ordinary  culture  media. 

The  disease  is  of  such  universal  occurrence  that 
many  of  its  peculiarities  are  well  known  to  all,  lay 
and  medical  alike.  It  is  not  at  all  contagious,  and 
no  special  means  of  disinfection  are  necessary. 
The  weak  and  sickly  are  more  liable  to  catch  it, 


MALARIA.  145 


but  few  escape  if  sufficiently  exposed.  Strangers 
visiting  Italy  often  fall  an  easy  prey  to  the  disease, 
because  they  are  careless  and  render  themselves 
liable  to  it.  This  they  do  by  spending  the  whole 
day  in  sight-seeing  without  stopping  for  the  proper 
amount  of  food  and  rest,  and  this  drain  on  even 
the  strongest  system,  kept  up  for  days  and  possibly 
weeks  at  a  time,  invites  an  attack  of  any  disease 
which  may  be  near  at  hand.  This  in  that  country 
is  usually  a  severe  form  of  malaria  or  perhaps 
typhoid  fever.  The  night  air  is  to  be  dreaded, 
not  because  it  contains  any  more  dangerous  in- 
gredient than  the  day  air,  but  because  it  helps  to 
cool  down  and  weaken  an  already  overtaxed 
system  and  bring  on  this  disease.  There  are  no 
particular  means  of  prevention  that  a  nurse  need 
especially  take. 


CHAPTER  XVI. 

THE  BACTERIA  OF  SURGICAL  DISEASES. 

In  spite  of  the  numerous  changes  and  improve- 
ments in  the  methods  used  in  antiseptic  surgery, 
all  writers  agree  in  giving  to  Sir  Joseph  Lister 
the  credit  of  having  first  used  modern  antiseptic 
methods  in  an  intelligent  way.  However  much 
we  may  have  changed  the  methods  of  protecting 
wounds,  the  principle  which  was  founded  by  Lis- 
ter remains  the  same.  It  is  on  this  common 
ground  of  surgical  antisepsis  and  asepsis  that  the 
surgeon  and  the  bacteriologist  meet. 

Even  before  the  days  of  Lister,  operators  had 
noticed  that  some  wounds  healed  at  once  without 
suppuration  or  inflammation,  while  others  suppu- 
rated and  healed  very  slowly  or  not  at  all.  Suppu- 
ration and  wound  infection  were  at  first  supposed 
to  be  caused  by  atmospheric  air,  and  hence  wounds 
were  treated  by  occlusion,  that  is,  they  were  sealed 
up  hermetically  This,  of  course,  kept  out  the  air, 
but  as  it  did  not  improve  the  condition  of  the 
146 


BACTERIA  OF  SURGICAL   DISEASES.      147 

wound,  it  began  to  dawn  on  the  minds  of  the  sur- 
geons that  perhaps  the  cause  of  infection  was  not 
the  air  itself,  but  something  in  the  air.  Then  the 
question  was  asked,  "  Where  was  this  infecting 
material,  and  how  did  it  get  into  the  wound  ?"  It 
might  be  on  the  patient,  on  the  instruments,  on 
the  operator,  or  in  the  air,  and  from  any  of  these 
places  it  may  get  into  the  wound  and  infect  it. 

In  order  to  remove  the  infecting  material  from 
these  various  places,  we  employ  antisepsis  to 
destroy  it,  and  endeavor  to  get  a  condition  of 
asepsis.  By  antisepsis  we  mean  a  means  employed 
to  destroy  the  activity  and  even  the  life  of  the 
infecting  organism.  If  we  succeed  in  this,  then  a 
condition  of  asepsis,  or  entire  absence  of  infection, 
is  obtained.  As  prevention  is  the  aim  of  modern 
medicine,  we  endeavor  to  prevent  the  contamina- 
tion of  wounds  rather  than  attempt  to  clean  them 
after  contamination  has  occurred. 

Now,  not  only  are  the  expressions,  asepsis,  anti- 
sespis,  not  clear  to  many  nurses,  but  even  physi- 
cians have  a  very  hazy  idea  as  to  what  these  words 
mean.  All  tissues  of  the  dead  body  will  become 
putrid  under  certain  circumstances,  such  as  moist- 


148  HYGIENE   OF  THE  SICK-ROOM. 

ure,  warmth,  and  the  presence  of  bacteria.  Ab- 
sence of  any  of  these  factors  will  prevent  decom- 
position. The  thrifty  house-wife  first  boils  her 
fruit  or  preserves  and  then  seals  them  in  air-tight 
vessels  while  hot,  thus  destroying  all  bacteria  and 
preventing  the  ingress  of  new  growths.  Perfect 
sterilization  lasts  only  so  long  as  the  object  or 
place  is  properly  protected,  contact  or  exposure, 
even  for  the  shortest  possible  time,  causing  con- 
tamination. As  already  related  in  a  previous 
chapter,  fire  is  the  most  perfect  sterilizer,  and 
exposure  to  heat  for  a  sufficient  length  of  time 
will  effectually  and  certainly  destroy  any  known 
micro-organism.  A  facetious  writer,  in  speaking 
of  our  "  invisible  foes,"  the  bacteria,  and  the 
extreme  difficulty  or  even  impossibility  of  com- 
pletely sterilizing  the  human  body,  said  that 
when  Shadrach,  Meshach,  and  Abednego  emerged 
from  the  seven-times-heated  fiery  furnace,  into 
which  they  had  been  cast  by  the  order  of  Nebu- 
chadnezzar, they  were  thoroughly  sterilized. 

Before  performing  an  operation,  the  surgeon  first 
destroys  any  germs  that  may  be  present  by  the  use 
of  antisepsis,  and  this  done,  he  prevents  the  ingress 


BACTERIA   OF  SURGICAL   DISEASES.      149 

of  further  bacteria  by  strict  asepsis.  Thus  the  rule 
in  surgical  operations  is,  antisepsis  up  to  the  time 
of  operation,  and  then  asepsis.  An  exposed  wound, 
whether  accidental  or  made  in  the  course  of  an 
operation,  offers  every  inducement  for  bacteria,  to 
grow ;  the  blood,  the  tissues  exposed,  the  dust,  con- 
taining germs  and  falling  on  the  wound,  all  cause 
disease.  They  cause  disease  by  being  carried 
through  the  circulation  to  other  parts  of  the 
body,  or  else  the  ptomaines,  that  is,  the  poisons 
which  the  bacteria  secrete,  are  distributed  over  the 
body  through  the  circulation.  Not  only  will  these 
ptomaines  get  into  the  small  lymphatic  channels 
and  be  absorbed  and  cause  septic  fever,  but  the 
bacteria  themselves  are  taken  up  by  the  vessels 
and  are  carried  to  different  parts  of  the  body,  pro- 
ducing what  are  called  metastases,  or  secondary 
deposits  of  the  disease.  This  is  familiar  in  the 
boils  which  so  often  appear  in  numbers  in  weak- 
ened individuals.  There  are  so  many  dangers  from 
this  that  it  seems  almost  hopeless  to  try  to  avoid 
the  "  ubiquitous  bacillus."  In  the  first  place,  the 
dust  in  operating  rooms  is  a  source  of  danger,  and, 
notwithstanding  the  fact  that  modern  operating 


150  HYGIENE   OF   THE  SICK-ROOM. 

rooms  are  carefully  built,  dust  is  always  present, 
especially  in  adjoining  rooms  and  in  the  outer  air, 
and  this  dust  brings  with  it  bacteria. 

The  ideal  operating  room  has  smooth,  kalso- 
mined  walls  with  rounding  corners,  smooth  wash- 
boards gently  curved  to  meet  the  floor,  hard  wood 
floor,  highly  polished,  with  as  few  and  as  small 
cracks  as  possible,  no  hangings,  no  rugs,  no  mat- 
ting, glass  and  metal  instrument  table,  plain  opera- 
ting table,  preferably  of  metal,  instruments  easy  to 
clean  and  with  few  cracks  or  angles  for  bacteria  to 
lodge  in.  Notwithstanding  these  elaborate  precau- 
tions and  the  methods  of  antisepsis  just  explained, 
bacteria  and  dust  containing  bacteria  do  get  in. 

The  calculation  of  the  number  of  bacteria  in 
cities  by  an  ingenious  Frenchman  is  interesting 
if  not  startling  : — 

"  The  number  of  bacteria  on  the  top  of  a  high 
mountain  is  one  to  the  cubic  meter.  In  the  Pare  de 
Montsouris,  in  the  south  of  Paris,  he  found  480 
bacteria  to  the  cubic  meter  of  air,  whilst  in  the  Rue 
de  Rivoli  the  proportion  was  3480.  In  a  new 
room  in  the  Rue  Censier  he  found  4500  to  the 
cubic  meter — more,  that  is  to  say,  than  in  the 


BACTERIA  OF  SURGICAL  DISEASES.      151 

centre  of  Paris  in  the  open  air.  In  a  room  in  the 
Rue  Monge,  he  counted  36,000,  in  the  H6tel  Dieu 
40,000,  and  in  the  Pitie,  an  older  hospital,  319,000 
bacteria  to  the  cubic  meter.  At  the  Observatory 
Montsouris,  650,000  bacteria  were  found  in  a  gram 
(15  grains)  of  dust;  in  the  room  in  the  Rue  Monge 
the  amount  was  2,100,000.  In  the  hospitals  the 
proportion  was  so  high  that  counting  the  number 
of  bacteria  in  a  whole  gram  of  dust  was  found 
impossible. 

"The  dust  is  the  great  conveyer  of  micro-organisms. 
At  2  A.M.,  when  a  city  is  most  quiet,  the  fewest 
germs  are  to  be  found  in  the  air ;  at  8  A.  M.  the 
industry  of  domestic  servants  and  dustmen  has 
already  made  the  air  to  teem  with  bacteria.  At  7 
P.M.  it  is  once  more  high,  for  many  houses  are  being 
'  tidied  up  '  besides,  sundry  kitchen  operations  are 
unhygienic.  Thus  the  'small  hours'  unfavorable  in 
many  respects  to  patients  hovering  between  life  and 
death,  are  the  least  septic  of  the  twenty-four.  The 
day  proportions  indicate  that  household  duties 
cause  more  septic  diffusion  than  is  excited  by 
traffic  and  industry.  Thus  the  value  of  residence 


152  HYGIENE   OF   THE  SICK-ROOM. 


at  the  seaside  and  on  mountain  peaks  is  scientifi- 
cally demonstrated." 

While  these  statistics  may  be  well  worth  not- 
ing, it  would  hardly  repay  any  one  to  live  on  a 
mountain  peak  to  avoid  the  bacteria.  The  presence 
of  bacteria  in  the  air  and  in  other  places,  however, 
does  show  the  necessity  of  proper  precaution  in 
performing  surgical  operations,  and  it  also  shows 
that  bacteriology,  or  the  study  of  these  bacteria, 
has  opened  a  new  era  for  surgery.  The  knowl- 
edge gained  from  this  new  branch  of  medicine  has 
opened  new  fields  of  usefulness  for  the  surgeon,  so 
that  many  diseases  formerly  treated  by  drugs  are 
now  treated  with  success  by  surgery. 

In  the  prefatory  chapter  to  his  well-written 
work,  "  Aseptic  and  Antiseptic  Surgery,"  Dr.  Ger- 
ster  says : — "  To  a  large  number  of  medical  men 
the  aseptic  and  antiseptic  methods  present  an  incon- 
gruous chaos  of  seemingly  contradictory  and  often 
incomprehensible  detail,  arbitrary  and  varying,  ac- 
cording to  the  predilections  or  whims  of  this  or 
that  teacher.  Yet  the  principle  involved  is  based 
on  the  correct  observation  of  a  common  biological 


BACTERIA  OF  SURGICAL  DISEASES.      153 

process,  namely,  that  of  the  decomposition  of  or- 
ganic substances.  The  well-known  methods  em- 
ployed since  the  earliest  dawn  of  civilization  for 
the  preservation  of  organic,  especially  animal, 
substances  are  based  upon  the  empirical  yet 
correct  appreciation  of  the  causes  of  putrefaction, 

and  the  practical  adaptation  of  these  methods  to 

>  • 

the  healing  of  operative  or  accidental  wounds 
contains  the  whole  essence  of  the  new  surgery. 
Evils  that  former  generations  of  surgeons  de- 
plored, but  could  not  effectually  combat,  such 
as  septicaemia,  pyaemia,  hospital  gangrene,  and 
erysipelas,  have  been  much  abated  as  a  direct 
consequence  of  a  clear  understanding  of  their 
essential  nature  and  causation. 

''Prevention  has  become  the  watchword  of 
modern  practice,  and  it  can  be  said  that,  by  the 
successful  employment  of  the  preventive  methods 
of  the  present  day,  surgery  has  become  a  conser- 
vative branch  of  the  healing  art.  The  elimination 
of  the  accidental  disturbances  of  repair  caused  by 
wound  infection  has  depressed  the  percentage  of 
mortality  following  amputation  of  the  extremities 
from  an  average  of  thirty-five  per  cent,  to  about 


154  HYGIENE   OF  THE  SICK-ROOM. 

fifteen  per  cent.  The  dread  of  undertaking  and 
submitting  to  a  surgical  operation  has  greatly 
diminished,  and  timely — that  is,  early — surgical  in- 
terference has  become  more  and  more  frequent,  to 
the  great  advantage  of  both  patient  and  physician. 
"  The  fear  of  suppuration,  with  its  dreadful  con- 
sequences, does  not  stay  now  the  hand  of  the 
surgeon,  as  of  old,  when  an  operation  was  always 
considered  a  forlorn  hope  and  a  last  resort.  The 
principle  underlying  antiseptic  surgery  has  ceased 
to  be  the  subject  of  serious  controversy.  The 
methods  of  wound  treatment  are,  to  a  certain 
extent,  still  undergoing  changes,  hence  should 
not  be  accepted  as  final.  Yet  it  is  undeniable 
that,  as  the  clearness  of  the  simple  principle  of 
asepticism  applied  to  wound  treatment  has  ad- 
vanced, so  the  frequent  changes  and  bewildering 
vacillations  characteristic  of  the  experimental 
stage  of  the  new  discipline  have  naturally  given 
way  to  steadier  methods.  At  present,  changes 
are  not  so  frequent  as  formerly,  yet  progress, 
especially  the  conquest  of  new  fields  for  the 
legitimate  practice  of  active  surgery,  is  not  at  a 
standstill." 


BACTERIA  OF  SURGICAL  DISEASES.      155 

This  is  quoted  at  such  length  to  impress  the 
importance  of  cleanliness  in  surgical  operations. 
Indeed,  it  has  been  stated  that  more  deaths  have 
been  caused  on  the  battlefield  by  bacteria  than  by 
the  sword. 

The  bacteria  of  surgical  diseases  are  principally 
the  organisms  of  suppuration,  pyaemia,  septicaemia, 
and  erysipelas.  The  most  common  cause  of  sup- 
puration or  pus  formation  is  a  micrococcus  called 
from  the  golden  yellow  color  of  the  mould  it  forms 
in  cultures,  staphylococcus  pyogenes  aureus,  or 
the  golden  grape  coccus.  These  micrococci  are 
arranged  together  in  bunches  like  grapes  and 
are  found  in  almost  all  forms  of  acute  suppu- 
ration. Another  micrococcus  of  suppuration  is 
the  staphylococcus  pyogenes  albus,  or  white  grape 
coccus.  Under  the  microscope  it  is  exactly  like 
the  last  variety,  but  in  cultures  it  is  white  and 
not  yellow.  Another  form  is  called  the  strepto- 
coccus pyogenes,  or  pus-generating  chain  coccus, 
because  it  grows  in  cultures  to  long  chains. 
These  three,  then,  are  the  principal  causes  of  sup- 
puration. 

All  forms  of  suppuration    owe   their  origin  to 


156  HYGIENE   OF   THE  SICK-ROOM. 

infection  from  without.  This  infection  in  the 
form  of  these  organisms  may  enter  the  body  by 
lesions  of  the  skin,  mucous  membrane  of  the 
digestive,  respiratory,  or  genito-urinary  tract 
Wounds  that  bleed  freely  do  not  usually  sup- 
purate, because  the  flowing  blood  washes  away 
the  organisms,  and  large  wounds  demand  medical 
attention  and  thus  often  avoid  suppuration,  but  the 
small,  jagged  wound  that  does  not  bleed,  the  wound 
inflicted  by  a  blunt  and  unclean  instrument,  is  apt 
to  suppurate.  In  the  mouth,  wounds  may  cause 
suppuration,  although  the  saliva  is  apt  to  prevent 
this.  As  long  as  the  skin  is  intact  no  infection  or 
suppuration  will  take  place,  but  let  the  skin  be  ex- 
coriated or  rubbed,  or  let  the  hand  be  constantly 
bruised  by  the  use  of  a  Jool,  as  in  working  or  in 
rowing,  and  the  lacerated  skin  may  take  up  pus 
organisms,  and  the  constant  working  of  the  hands 
and  fingers  will  cause  the  germs  to  spread  by  the 
lymphatics  to  other  parts  of  the  body. 

A  very  common  way  of  carrying  infection  from 
one  part  of  the  body  to  the  other  is  by  scratching, 
the  organisms,  being  carried  under  the  nails,  are 
inoculated  into  the  skin  by  the  edges  of  the  nails. 


BACTERIA   OF  SURGICAL  DISEASES.      157 


The  relation  of  the  diseases  of  suppuration  to  sep- 
ticaemia and  pyaemia  is  a  very  close  one.  Liter- 
ally, septicaemia,  is  defined  as  an  infective  disease 

• 

caused  by  the  absorption  of  septic  or  poisonous 
products,  while  pyaemia  is  septicaemia  with  the 
formation  of  secondary  abscesses.  That  is,  they 
are  both  probably  caused  by  the  pus  organism,  but 
in  septicaemia  the  disease  is  not  carried  all  over  the 
body,  while  in  pyaemia  the  pus  organism  is  carried 
by  the  circulation  to  other  parts  of  the  body,  caus- 
ing the  formation  of  secondary  abscesses,  called 
also  metastatic  abscesses. 

The  whole  idea  of  antiseptic  surgery  is  to 
thoroughly  clean  the  part  of  the  patient  to  be 
operated  on,  clean  the  operators'  hands,  instru- 
ments, and  everything  else  used.  The  rules  laid 
down  by  Gerster  in  his  "Surgery"  are  that  the 
hands  and  forearms,  especially  the  finger-nails,  of  the 
surgeon  and  his  assistants  should  be  well  scrubbed 
in  hot  water  with  soap  and  brush  for  five  minutes ; 
likewise  the  region  of  the  body  of  the  patient  to 
be  operated  on,  after  carefully  shaving  off  the  hair. 
After  this  follows  an  immersion  of  the  hands  in 
corrosive  sublimate  lotion  for  one  minute.  All 


158  HYGIENE   OF  THE  SICK-ROOM. 

rings,  bangles,  and  bracelets  should  be  removed 
from  surgeons  and  nurses.  Instead  of  the  corro- 
sive sublimate  solution,  green  soap  may  be  used. 

• 
The  instruments  should  be  subjected  to  a  careful 

and  minute  cleansing  with  soap  and  brush,  especial 
care  being  taken  to  remove  dry  particles  of  blood, 
pus,  etc.,  from  the  grooves  and  behind  the  clasps  of 
the  more  composite  instruments,  which  ought  to 
be  taken  apart  each  time  for  cleansing.  They 
should  be  immersed  for  ten  minutes  in  a  three 
per  cent,  solution  of  carbolic  acid  before  use.  As 
few  instruments  as  possible  should  be  used,  and 
they,  simple,  smooth,  and  well-polished.  During 
the  operation  the  wound  should  be  freely  and  fre- 
quently irrigated  with  the  proper  kind  of  a  disin- 
fecting fluid ;  the  hands  of  the  surgeon  and  his 
assistants  should  be  also  washed  at  not  too  long 
intervals  in  a  disinfecting  fluid  (corrosive  sublimate, 
I  :  1000) ;  the  instruments  should  be  kept  immersed 
in  a  three  per  cent,  solution  of  carbolic  acid  (which 
is  least  injurious  to  them). 

If  the  surgeons  or  nurses'  touch  a  not  disin- 
fected object  the  hands  must  be  disinfected  anew. 
Sponges  should  be  beaten  free  from  calcareous 


BACTERIA  OF  SURGICAL  DISEASES.      159 


particles,  then  immersed  for  fifteen  minutes  in 
dilute  muriatic  acid  to  dissolve  the  remnant  of 
lime,  washed  in  cold  water,  then  thoroughly 
kneaded  by  hand  with  green  soap  in  hot  water 
for  five  minutes,  rinsed,  and  then  immersed  in  a 
five  per  cent,  solution  of  carbolic  acid,  in  which 
they  remain  until  required  for  use.  Sponges  used 
in  an  antiseptic  operation  can  be  used  again. 
Careful  washing  out  with  green  soap  and  hot 
water  of  all  the  remnants  of  fibrin  and  blood,  then 
immersion  in  a  five  per  cent,  solution  of  carbolic 
acid,  is  sufficient.  It  is  not  good  to  use  too  many 
sponges  at  an  operation.  When  saturated  with 
blood  at  an  operation,  they  should  be  washed  free 
from  it  in  hot  water,  then  thrown  into  a  basin 
filled  with  a  carbolic  acid  solution,  and  hence 
handed  to  the  surgeon.  Carbolic  acid  is  prefer- 
able for  the  preservation  of  sponges  until  used 
because  it  does  not  become  decomposed  and  inert, 
as,  for  instance,  corrosive  sublimate. 

Ordinarily,  the  two  disinfecting  solutions  above 
mentioned  will  usually  be  found  sufficient,  and 
they  have  the  further  advantage  of  being  easily 
procurable.  Boiled  water  as  a  solvent  for  these 


160  HYGIENE   OF  THE  SICK-ROOM. 


substances  is  to  be  preferred.  A  convenient  and 
ready  way  of  mixing  the  carbolic  acid  solution, 
is  to  add  one  tablespoonful  or  four  teaspoonfuls 
of  pure  carbolic  acid  to  a  quart  bottle  of  hot 
water.  This  will  make  a  solution  of  the  strength 
of  about  three  per  cent,  reckoning  650  grams  to 
the  ordinary  wine-bottle.  The  corrosive  subli- 
mate solution  may  be  easily  made  by  using  the 
compressed  tablets  of  corrosive  sublimate  and 
ammonium  chloride,  as  put  up  by  Sharp  and 
Dohme,  of  Baltimore,  and  other  reliable  manu- 
facturing chemists.  Each  tablet  is  composed  of 
7.3  grains  of  corrosive  sublimate  and  7.7  grains 
of  ammonium  chloride,  which,  when  dissolved  in 
one  pint  of  water,  will  give  a  solution  of  I  :  1000. 
Sufficient  green  coloring  matter  of  neutral  and 
innocuous  properties  is  added  to  render  them 
distinctive  and  prevent  mistakes.  The  ammo- 
nium chloride  is  added  to  facilitate  solution 
and  prevent  decomposition  of  the  corrosive  sub- 
limate when  dissolved  in  ordinary  spring  or  well 
water. 

Dr.  John  B.  Roberts,  of  Philadelphia,  has  formu- 
lated the  following,  to  be  observed  in  operations 


BACTERIA   OF  SURGICAL   DISEASES.      161 


at  his  clinic  at  the  Woman's  Medical  College 
Hospital  of  that  city : — 

"After  wounds  or  operations,  high  temperature 
usually,  and  suppuration  always,  are  due  to  blood 
poisoning,  which  is  caused  by  infection  with  vege- 
table parasites  called  bacteria. 

"  These  parasites  ordinarily  gain  access  to  the 
wound  from  the  skin  of  the  patient,  the  finger- 
nails or  hands  of  the  operator  or  his  assistants, 
the  ligatures,  sutures,  or  dressings. 

"  Suppuration  and  high  temperature  should  not 
occur  after  operation  wounds  if  no  suppuration  has 
existed  previously. 

"  Bacteria  exist  almost  everywhere  as  invisible 
particles  in  the  dust ;  hence  everything  that  touches 
or  comes  into  even  momentary  contact  with  the 
wound  must  be  germ-free — technically  called 
'  sterile'. 

"A  sterilized  condition  of  the  operator,  the 
assistant,  the  wound,  instruments,  etc.,  is  obtained 
by  removing  all  bacteria  by  means  of  absolute 
surgical  cleanliness  (asepsis),  and  by  the  use  of 
those  chemical  agents  which  destroy  the  bacteria 
not  removed  by  cleanliness  itself  (antisepsis). 


1 62  HYGIENE   OF  THE  SICK-ROOM. 


"  Surgical  cleanliness  differs  from  the  housewife's 
idea  of  cleanliness  in  that  its  details  seem  frivolous, 
because  it  aims  at  the  removal  of  microscopical 
particles.  Stains  such  as  housewives  abhor,  if  germ- 
free,  are  not  objected  to  in  surgery. 

"  The  hands  and  arms,  and  especially  the  finger- 
nails, of  the  surgeon,  assistants,  and  nurses  should 
be  well  scrubbed  with  hot  water  and  soap  by 
means  of  a  nail-brush  immediately  before  the  op- 
eration. The  patient's  body  about  the  site  of  the 
proposed  operation  should  be  similarly  scrubbed 
with  a  brush  and  cleanly  shaved.  Subsequently 
the  hands  of  the  operator,  assistants,  and  nurses 
and  the  field  of  operation  should  be  immersed  in,  or 
thoroughly  washed  with,  corrosive  sublimate  solu- 
tion (i  :  1000  or  I  :  2000).  Finger-rings,  bracelets, 
bangles,  and  cuffs  worn  by  the  surgeon,  assistants, 
or  nurses  must  be  removed  before  the  cleansing  is 
begun,  and  the  clothing  covered  by  a  clean  white 
apron,  large  enough  to  extend  from  neck  to  ankles 
and  provided  with  sleeves. 

"  The  instruments  should  be  similarly  scrubbed 
with  hot  water  and  soap,  and  all  particles  of  blood 
and  pus  from  any  previous  operation  removed  from 


BACTERIA  OF  SURGICAL  DISEASES.      163 

the  joints.  After  this  they  should  be  immersed  for 
at  least  fifteen  minutes  in  a  solution  of  beta-naphthol 
(i  :  2500),  which  must  be  sufficiently  deep  to  cover 
every  portion  of  the  instruments.  After  cleansing 
the  instruments  with  soap  and  water,  baking  in  a 
temperature  a  little  above  the  boiling-point  of  water 
is  the  best  sterilizer.  During  the  operation  the 
sterilized  instruments  should  be  kept  in  a  beta- 
naphthol  solution  and  returned  to  it  when  the 
operator  is  not  using  them. 

"  The  antiseptic  solutions  mentioned  here  are  too 
irritating  for  use  in  operations  within  the  abdo- 
men and  pelvis.  Water  made  sterile  by  boiling 
is  usually  the  best  agent  for  irrigating  these 
cavities  and  for  use  on  instruments  and  sponges. 
(The  instruments  and  sponges  must  be  well  steril- 
ized.) 

"  Sponges  should  be  kept  in  a  beta-naphthol 
or  a  corrosive  sublimate  solution  during  the  opera- 
tion. After  the  blood  from  the  wound  has  been 
sponged  away,  they  should  be  put  in  another 
basin  containing  the  antiseptic  solution  and 
cleansed  anew  before  being  used  again.  The 
antiseptic  sutures  and  ligatures  should  be  simi- 


1 64  HYGIENE   OF  THE  SICK-ROOM. 

larly  soaked  in  beta-naphthol  solution  during  the 
progress  of  the  operation. 

"  No  one  should  touch  the  wound  but  the  oper- 
ator and  his  first  assistant.  No  one  should  touch 
the  sponges  but  the  operator,  his  first  assistant,  and 
the  nurse  having  charge  of  them.  No  one  should 
touch  the  already-prepared  ligatures  or  instru- 
ments except  the  surgeon  and  his  first  and  second 
assistants. 

"  None  but  those  assigned  to  the  work  are 
expected  to  handle  instruments,  sponges,  dress- 
ings, etc.,  during  the  operation. 

"When  any  one  taking  part  in  the  operation 
touches  an  object  not  sterilized,  such  as  a  table,  a 
tray,  or  the  ether  towel,  he  should  not  be  allowed  to 
touch  the  instruments,  the  dressings,  or  the  liga- 
tures, until  his  hands  have  been  again  sterilized.  It 
is  important  that  the  hands  of  the  surgeon,  his 
assistants,  and  nurses  should  not  touch  any  part  of 
their  own  bodies,  nor  of  the  patient's  body,  except 
at  the  sterilized  seat  of  the  operation,  because  infec- 
tion may  be  carried  to  the  wound.  Rubbing  the 
head  or  beard  or  wiping  the  nose  requires  imme- 
diate disinfection  of  the  hands  to  be  practiced. 


BACTERIA  OF  SURGICAL  DISEASES.      165 

"  The  trailing  ends  of  ligatures  and  sutures 
should  never  be  allowed  to  touch  the  surgeon's 
clothing  or  to  drag  upon  the  operating  table, 
because  such  contact  may  occasionally,  though 
not  always,  pick  up  bacteria,  which  may  cause 
suppuration  in  the  wound. 

"  Instruments  which  fall  upon  the  floor  should 
not  be  again  used  until  thoroughly  disinfected. 

"  The  clothing  of  the  patient  in  the  vicinity  of 
the  part  to  be  operated  upon,  and  the  blankets  and 
sheets  used  there  to  keep  him  warm,  should  be 
covered  with  dry  sublimate -towels.  All  dressings 
should  be  kept  safe  from  infection  by  being  stored 
in  glass  jars  or  wrapped  in  dry  sublimate  towels." 

Experiments  recently  performed  at  the  Johns 
Hopkins  Hospital  on  the  disinfection  of  the  skin, 
and  especially  the  hands,  have  yielded  some  new 
and  very  interesting  results.  It  was  at  one  time 
supposed  that  the  bringing  of  powerful  disinfect- 
ants in  contact  with  the  skin  was  sufficient  to 
thoroughly  disinfect  it.  It  is  now  known  that  the 
presence  of  natural  oil  and  fat  on  the  skin  is  suffi- 
cient to  prevent  the  action  of  these  substances.  Dr. 
Wm.  H.  Welch  has  found  and  described  an  organ- 


1 66  HYGIENE   OF  THE  SICK-ROOM. 

ism  which  he  calls  the  white  staphylococcus,  or  sta- 
phylococcus  albus  epidermis,  because  it  is  found  not 
only  on  the  skin,  but  in  the  deeper  layers  of  the 
skin  which  escape  the  ordinary  methods  of  skin 
disinfection.  What  the  exact  significance  of  this 
organism  is  is  not  easy  to  say,  but  it  has  been 
found  in  certain  morbid  conditions  where  its  pres- 
ence was  very  suspicious. 

This  organism  was  found  and  studied  by  pass- 
ing thoroughly  sterilized  threads  through  the 
previously  sterilized  skin  and  then  putting  these 
threads  in  culture  tubes,  as  already  explained,  when 
'  a  growth  of  this  white  staphylococcus  would  soon 
appear.  This  organism  on  the  hands  could  cause 
infection  when  the  hands  had  apparently  been  tho- 
roughly disinfected  by  the  ordinary  methods.  This 
is  supposed  to  be  the  cause  of  the  stitch  abscess 
and  the  suppuration  that  so  frequently  occurs 
around  drainage  tubes. 

For  this  reason  some  advanced  surgeons  have 
abandoned  the  use  of  skin  stitches  and  drainage 
tubes,  a  thing  which  may  be  considered  by  some 
as  doubtful  progress. 

Dr.   Welch    says,   in   an   address    read   at   the 


BACTERIA  OF  SURGICAL   DISEASES.      167 

Second  Congress  of  American  Physicians  and 
Surge\>ns,  in  Washington :  "  The  demonstration  of 
micro-organisms  in  layers  of  the  epidermis  deeper 
than  can  be  disinfected  by  present  methods  sug- 
gests that  more  attention  than  seems  now 
to  be  customary  should  be  paid  to  the,  skin 
of  the  patient  as  a  source  of  traumatic  infections. 
It  also  admonishes  us  to  receive  with  caution  the 
statements  recently  made  concerning  the  elimi- 
nation in  suppurative  diseases  of  staphylococci 
by  the  sweat. 

"  The  conditions  for  the  efficient  action  of 
chemical  disinfectants  have  been  found  to  be  far 
more  complicated  and  less  easily  controlled  than 
was  formerly  supposed,  and  the  substitution,  wher- 
ever applicable,  of  the  simple  and  certain  methods 
of  disinfection  by  heat,  such  as  have  been  long 
employed  in  bacteriological  laboratories,  is  to  be 
commended.  Chemical  disinfectants  still  have 
their  place  for  many  purposes  in  the  operating- 
room,  but  their  place  is  not  in  fresh,  healthy 
wounds. 

"  Thorough  scrubbing  of  the  skin  with  soap 
and  warm  water  by  a  sterilized  brush  removes 


168  HYGIENE   OF  THE  SICK-ROOM. 

many  bacteria,  but  not  all,  and  it  cannot  be  re- 
garded as  a  satisfactory  means  of  cutaneotfs  dis- 
infection. 

"  The  fallacy  in  previous  work  on  disinfection 
of  the  skin  with  corrosive  sublimate  has  been 
that  in  testing  its  efficiency  the  sublimate  was 
not  first  precipitated  by  sulphide  of  ammonium.  If 
this  precaution  be  first  observed,  it  will  be  found 
that  corrosive  sublimate  accomplishes  much  less 
than  is  generally  supposed.  Our  revision  of 
the  work  relating  to  cutaneous  disinfection  with 
sublimate  has  led  to  some  curious  and  interesting 
observations,  and  to  results  which  at  first  seemed 
paradoxical. 

"  By  examining  the  hands  of  surgeons  who  are 
in  the  habit  of  washing  them  daily  in  solutions  of 
corrosive  sublimate,  it  was  found  that  the  mercury 
becomes  so  intimately  incorporated  with  the  epi- 
dermis that  its  presence  there  can  be  demon- 
strated by  means  of  sulphide  of  ammonium  at 
least  six  weeks  after  any  contact  with  mercurial 
solutions  has  taken  place.  Micrococci  in  the  epi- 
dermis which  have  not  been  killed  by  washing  in 
sublimate  solutions,  but  which  have  been  brought 


BACTERIA   OF  SURGICAL  DISEASES.      169 


into  such  relation  to  the  sublimate  that  even  after 
prolonged  washing  of  the  skin  with  alcohol  and 
water  they  will  not  grow  on  culture  media 
until  the  skin  is  washed  with  sulphide  of  ammo- 
nium, may  also  remain  a  long  time  in  the  epi- 
dermis. 

"  Hence,  it  may  happen  that  prolonged  scrubbing 
of  the  hands  of  such  persons  simply  with  soap  and 
warm  water  may  remove  so  many  superficial  bacteria 
that  the  cultures  from  the  scrapings  of  the  epider- 
mis may  show  very  few,  occasionally  even  no,  colo- 
nies :  whereas,  when  this  is  followed  by  washing  in 
sublimate  and  then  in  sulphide  of  ammonium,  a 
much  larger  number  of  colonies  appear  in  the  cul- 
tures. The  apparently  paradoxical  result,  which 
is  obtained  only  from  the  hands  of  those  who  have 
previously  washed  them  in  sublimate  solution,  has 
no  reference  to  the  application  of  the  sublimate 
immediately  after  the  soap  and  water,  but  it  is 
to  be  explained  by  the  liberation,  by  means  of 
sulphide  of  ammonium,  of  the  bacteria  held  in 
check  by  the  mercury  used,  it  may  be,  several 
days  before  the  experiment.  The  same  result  is, 
of  course,  obtained  if  the  sulphide  of  ammonium 


170  HYGIENE  OF  THE  SICK-ROOM. 

be   applied  immediately  after  the   scrubbing  with 
soap  and  water. 

"  These  observations  upon  the  persistence  of 
mercury  in  the  epidermis  and  its  long-continued 
inhibition  of  the  growth  of  bacteria,  make  it  neces- 
sary in  all  work  upon  disinfection  of  the  hands  to 
first  precipitate  the  mercury  with  sulphide  of  am- 
monium whenever  the  experiments  are  to  be  made 
upon  hands  which  have  been  washed  in  sublimate 
solutions,  even  if  it  has  occurred  a  long  time  previ- 
ously. Exactly  what  relation  the  mercury  in  the 
epidermis  holds  to  the  bacteria  which  it  does  not 
destroy,  but  whose  growth  in  our  nutrient  media  it 
prevents,  we  cannot  say.  We  may,  perhaps,  think 
of  these  bacteria  as  enveloped  in  an  albuminous 
combination  of  mercury.  One  thing  is  certain — 
that,  when  the  sublimate  has  been  as  thoroughly 
washed  off  from  the  skin  as  possible  with  water,  or 
has  been  applied  days  before,  the  nutrient  gelatine 
or  agar  is  not  rendered  unfit  for  the  growth  of  bac- 
teria by  the  mere  presence  of  the  small  quantity  of 
mercury  carried  into  it  with  scrapings  from  the  epi- 
dermis, for  the  bacteria  which  have  reached  the 
epidermis  after  the  application  of  the  sublimate — 


BACTERIA  OF  SURGICAL  DISEASES.      171 


and  these  are  often  identical  with  those  inhibited 
by  the  mercury — develop  as  usual.  It  is  only  those 
bacteria  which  were  originally  brought  into  contact 
with  the  sublimate  in  some  such  manner  as  that 
suggested,  which  will  not  grow  until  after  the  ap- 
plication of  sulphide  of  ammonium,  and  it  is  not — 
as  has  been  usually  supposed  in  other  observations 
of  a  similar  kind  in  disinfectant  experiments  with 
sublimate — the  alteration  of  the  nutrient  medium 
by  the  presence  of  a  trace  of  sublimate  which  in- 
hibits the  growth  of  the  colonies. 

"  As  to  the  practical  efficiency  of  disinfection  of 
the  skin  with  solutions  of  corrosive  sublimate,  it  is 
to  be  said  that  this  agent,  when  properly  applied, 
kills  most  of  the  bacteria  upon  the  surface  of  the 
skin.  The  washing  of  the  skin  with  alcohol  im- 
mediately before  the  use  of  the  sublimate  increases 
its  efficiency  to  a  marked  degree.  If  the  mercury 
after  the  employment  of  this  method  be  precipi- 
tated by  washing  the  hands  in  sulphide  of  am- 
monium, it  will  be  found  that  the  results  are  much 
less  favorable  than  would  appear  by  cultures  made 
from  the  skin  and  under  the  nails,  without  the  use 
of  sulphide  of  ammonium. 


i;2  HYGIENE   OF   THE  SICK-ROOM. 


"  It  is  especially  the  scrapings  under  the  nails 
and  around  the  matrix  of  the  nails  which  yield 
positive  results  when  ammonium  sulphide  is 
used,  but  often  negative  ones  without  this  precau- 
tion. 

"  It  may  be  urged  that  it  is  not  necessary  actu- 
ally to  kill  the  bacteria  upon  the  skin  ;  it  is  suffic- 
ient if  they  are  rendered  incapable  of  growth,  and 
as  most  of  those  which  are  not  killed  by  the  subli- 
mate do  not  grow  upon  our  ordinary  nutrient 
media,  it  is  reasonable  to  infer  that  they  will  not 
grow  in  wounds.  This  line  of  argument  certainly 
deserves  consideration ;  nevertheless,  there  is  no 
positive  proof  that  these  bacteria  will  not  grow  in 
wounds  under  some  conditions,  and  surely  one  will 
feel  safer  with  a  method  of  disinfection  which  actu- 
ally kills  the  bacteria. 

"The  best  results  have  been  obtained  in  disinfec- 
tion of  the  skin  by  the  following  method  : — 

"  i.  The  nails  are  kept  short  and  clean. 

"  2.  The  hands  are  washed  thoroughly  for 
several  minutes  with  soap  and  water,  the  water 
being  as  warm  as  can  be  comfortably  borne  and 
being  frequently  changed.  A  brush,  sterilized  by 


BACTERIA   OF  SURGICAL   DISEASES.      173 


steam,  is  used.  The  excess  of  soap  is  washed  off 
with  water. 

"  3.  The  hands  are  immersed  for  one  or  two 
minutes  in  a  warm,  saturated  solution  of  perman- 
ganate of  potash  and  are  rubbed  over  thoroughly 
with  a  sterilized  swab. 

"  4.  They  are  then  placed  in  a  warm,  saturated 
solution  of  oxalic  acid,  where  they  remain  until 
complete  decolorization  of  the  permanganate 
occurs. 

"5.  They  are  then  washed  off  with  sterilized 
salt  solution  or  water. 

"6.  They  are  immersed  for  two  minutes  in 
sublimate  solution,  I  :  500. 

"  The  bacteriological  examination  of  skin  thus 
treated  yields  almost  uniformly  negative  results, 
the  material  for  the  cultures  being  taken  from 
underneath  and  around  the  nails." 


CHAPTER  XVII. 

THE  BACTERIA  OF   THE  MOUTH. 

The  bacteria  of  the  mouth  are  very  numerous, 
including  not  only  those  which  are  always  present, 
or  rarely  absent,  but  also  the  accidental  ones. 
Among  the  former  are  found  a  great  number, 
some,  always  present,  whose  action  is  not  under- 
stood, some  which  evidently  play  an  important 
part  in  the  splitting  up  of  the  food  substances 
taken  and  assisting  digestion  and  assimilation, 
and  still  others  whose  action  under  certain  cir- 
stances  is  very  harmful. 

As  the  mouth  is  one  of  the  chief  avenues  of 
approach  through  which  bacteria  gain  access  to 
the  body,  it  is  not  surprising  that  certain  organisms 
of  well-known  diseases  have  been  found  in  the 
mouth  even  when  the  individual  did  not  have 
the  disease  caused  by  this  particular  organism. 
Thus  typhoid  fever,  Asiatic  cholera,  pneumonia, 
phthisis,  and  several  other  diseases  find  their  way 
to  the  body  through  the  mouth. 
174 


THE  BACTERIA    OF  THE  MOUTH.        175 

The  decay  of  the  teeth  is  supposed  to  be  caused 
by  micro-organisms  which  attack  them.  They 
probably  become  especially  active  when  the  chemi- 
cal composition  of  the  saliva  is  so  altered  that  its 
inhibitory  power  is  lost  or  permits  acid  fermen- 
tations. The  theory  is  that  either  the  micro- 
organisms find  their  way  into  the  teeth  and  the 
acid  of  the  abnormal  fermentation  enters  and 
does  the  harm,  or  else  the  acid  makes  a  way 
for  the  organisms  to  enter.  In  adults  occa- 
sionally, and  in  children  especially,  the  mouth  is 
apt  at  times  to  undergo  inflammation ;  that  is,  the 
mucous  membrane  lining  the  mouth  cavity  be- 
comes inflamed.  This  inflammation  may  assume 
different  forms,  and  one  form  is  called  parasitic, 
because  it  is  caused  by  a  minute  parasite.  This 
disease  is  called  the  thrush. 

Thrush  is  a  disease  characterized  "  by  inflam- 
mation of  the  mucous  surfaces,  the  peculiar 
feature  of  which  is  the  presence  of  points 
or  patches  of  a  curd-like  appearance  on  the  in- 
flamed surface."  It  occurs  in  children  of  all  ages 
from  a  few  weeks  up,  and  may  even  be  found, 
though  very  rarely,  in  adults.  The  most  common 


176  HYGIENE   OF   THE  SICK-ROOM. 

primary  causes  are  improper  feeding,  indigestion, 
inflammation  of  the  intestinal  tract,  general  weak- 
ness, and  such  causes.  It  is  a  common  disease  in 
foundling  hospitals,  in  crowded  tenement  houses, 
among  the  poor,  and  especially  where  the  infant 
is  bottle-fed.  It  is  a  parasitic  disease  and  com- 
municable by  contact. 

One  frequent  cause  among  foundlings  is  the 
use  of  a  common  nursing-bottle  not  properly 
cleansed,  so  that  the  disease  is  passed  from  infant 
to  infant.  An  ordinary  inflammation  of  the  mouth, 
called  a  stomatitis,  may  become  a  thrush  by  the 
presence  of  the  thrush  organism.  This  is  present 
in  the  form  of  little  white  points  visible  to  the 
naked  eye,  each  point  consisting  of  a  tangled 
mass  of  the  thrush  organism,  or  fungus,  as  it  is 
called.  The  thrush  fungus  is  different  from  the 
other  organisms  described  in  that  it  is  a  mould 
belonging  to  the  vegetable  parasites.  It  is  seen 
under  the  microscope  as  a  tangled  mass  of  deli- 
cate branching  filaments  which  grow  very  rapidly 
and  penetrate  into  the  layers  of  the  mucous  sur- 
faces. It  may  be  implanted  upon  an  inflamed 
mucous  surface  from  the  air,  but  the  most  com- 


THE  BACTERIA    OF   THE  MOUTH.         177 


mon  method  of  transplanting  it  is  by  the  nursing- 
bottle.  This  same  fungus  in  milk  causes  fermen- 
tation, and  undoubtedly  by  this  means  gives  the 
disease  to  children. 

In  children  thrush  soon  yields  to  treatment  if 
the  cause  is  removed ;  that  is,  in  children  ,under 
six  months,  but  in  children  over  that  age  it  often 
proves  very  obstinate.  As  victims  of  thrush 
generally  have  a  disordered  digestion,  the  latter 
needs  the  physician's  care  first,  especially  as  this 
indigestion  so  alters  the  composition  of  the  saliva 
that  the  fungus  flourishes  and  returns  even  when 
removed.  The  proper  local  treatment  is  to  thor- 
oughly cleanse  the  mouth  with  clean,  warm  water 
and  a  soft  linen  rag,  and  then  apply  on  a  rag 
ordinary  borax  dissolved  in  glycerin  and  water 
in  the  proportion  of  about  a  half  teaspoonful  of 
powdered  borax  to  three  ounces  of  water  and 
one  or  two  teaspoonfuls  of  glycerin.  Of  course, 
extended  treatment  should  be  left  to  the  physician, 
as  many  complications  of  the  disease  might  occur 
which  might  be  beyond  the  nurse's  knowledge. 

If  it  is  not  practicable  for  each  child  in  a  hos- 
pital to  have  its  own  nursing-bottle  separate  from 


178  HYGIENE   OF  THE  SICK-ROOM. 


all  others,  then  after  each  use,  the  whole  bottle, 
and  especially  the  tip,  should  be  thoroughly  ster- 
lized  by  boiling  in  water,  and  if  the  milk  is  sus- 
picious it  should  also  be  subjected  to  thorough 
sterilization.  In  most  diseases,  and  in  all  febrile 
diseases,  the  mouth  needs  the  constant  attention 
of  the  nurse. 

Every  one  has  felt  the  extreme  discomfort  of 
awakening  to  find  the  mouth  open,  the  tongue 
dry,  and  the  lips  parched.  This  in  health  is  of 
little  importance,  but  the  sick  suffer  particularly 
from  this  unpleasant  accompaniment  of  almost 
all  diseases,  namely,  that  of  a  dry  and  often  un- 
clean mouth.  The  nurse  who  knows  how  gently 
and  skillfully  to  cleanse  the  mouth  and  give  the 
lips  their  moist  feeling,  is  of  more  use  in  the 
sick-room  than  all  the  sympathizing  friends  com- 
bined. The  tongue,  which  has  always  been 
regarded  as  indicative  of  various  changes  in  the 
alimentary  canal,  should  not  escape  the  careful 
study  of  the  nurse. 

Normally,  the  tongue  is  of  a  dull  red  color, 
and  at  times  in  health  it  assumes  a  furry,  whitish 
look,  but  ordinarily  it  is  red.  Exceptionally,  some 


THE  BACTERIA    OF  THE  MOUTH.         179 

persons  have  a  tongue  always  coajted,  but  when 
we  see  a  tongue  covered  in  whole  or  in  part 
with  a  white,  grayish,  or  even  dark  fur,  it  is 
proper  to  look  for  the  cause.  The  popular  idea 
is  that  constipation  will  cause  the  tongue  to 
become  furred,  and  this  opinion  is  correct  as  far 
as  it  goes.  A  tongue  also  becomes  coated  when 
the  individual  is  confined  to  a  liquid  diet  or  when 
he  is  starved.  Patients  convalescing  and  on  a 
milk  diet  have  almost  always  a  very  white 
tongue.  This  white  fur  to  the  tongue  is  composed 
partly  of  minute  organisms  like  the  thrush  fun- 
gus in  form,  and  it  is  partly  epithelium,  which 
grows  very  quickly  on  the  tongue.  Ordinarily, 
in  health  the  constant  use  of  the  tongue  in  mas- 
tication rubs  off  this  epithelial  layer  as  fast  as  it 
is  formed,  and  the  organisms  do  not  have  a 
chance  to  grow  to  a  great  extent,  but  in  diseases 
where  the  patient  diets,  or  where  the  diet  is  liquid, 
the  epithelium  is  not  rubbed  off  and  is  allowed 
to  grow  and  be  colored  white  or  dark,  according 
to  the  color  of  the  food  or  medicine  taken.  In 
some  diseases  the  tongue  assumes  a  red  color 
and  is  very  dry.  As  this  hardly  belongs  to 


i8o  HYGIENE   OF   THE  SICK-ROOM. 


the  subject,  it  need  not  be  considered  further, 
but  it  may  be  said  that  the  altered  condition 
of  the  intestinal  tract  and  the  juices  secreted  by 
it  is  not  without  effect  on  the  secretion  of  the 
saliva  and  the  tongue. 

These  various  conditions  of  the  mouth  and 
the  tongue  need  attention  on  the  part  of  the 
nurse  much  more  frequently  than  other  condi- 
tions apparently  more  important.  The  excess 
of  fur  on  the  tongue  causes  a  very  unpleasant 
and  familiar  odor  to  be  generated  in  the  mouth 
of  the  unfortunate  patient,  and  the  nurse  should 
make  it  her  duty  to  cleanse  the  mouth  and  free 
it  from  the  excess  of  matter  many  times  during 
the  day  and  night,  and  especially  after  eating.  For 
this  purpose  a  soft,  clean  rag  and  warm  water 
may  be  used  as  a  preliminary. 

The  tongue  should  be  scraped  by  a  piece 
of  whalebone  or  an  ordinary  tongue-scraper  and 
the  mouth  be  washed  out  occasionally  with  a  mix- 
ture of  tincture  of  myrrh,  a  teaspoonful  to  a  half 
tumblerful  of  water.  To  this  may  be  added  a  half 
teaspoonful  of  the  chlorate  of  potash,  if  desirable. 
Borax  also  may  be  used  as  in  thrush.  If  the 


THE  BACTERIA    OF  THE  MOUTH.         181 


patient  is  able  to  expectorate,  the  mouth  may  be 
rinsed  out  with  a  solution  of  the  bichloride  of 
mercury  (i  :  2000),  if  great  caution  be  used  that 
none  is  swallowed,  and  the  mouth  then  be  washed 
out  with  water. 

The  care  of  the  mouth  is  one  of  the  most  im- 
portant of  the  nurse's  duties  and  one  most  appre- 
ciated by  the  sick  patient,  and  an  intelligent  atten- 
tion to  this  point  not  only  makes  the  patient  feel 
better  and  more  comfortable,  but  may  entice  a  very 
sick  person  to  eat  who  otherwise  would  not  care 
to  do  it. 


CHAPTER  XVIII. 

OPHTHALMIA  NEONATORUM. 

Ophthalmia  neonatorum  is  a  purulent  inflam- 
mation in  the  new-born,  of  the  conjunctiva  or 
mucous  membrane  lining  the  eyeball  and  the 
inner  parts  of  the  lid.  Its  synonyms  are  purulent 
ophthalmia,  gonorrhceal  ophthalmia,  blennorrhoea 
of  the  conjunctiva,  and  purulent  conjunctivitis. 
It  is  due  to  an  organism  called  the  gonococcus 
or  micrococcus  of  gonorrhoea,  and  is  usually 
transmitted  to  the  eyes  of  the  new-born  child  by 
the  diseased  condition  of  the  genital  tract  of  the 
mother.  The  organism  is  the  specific  germ  of 
gonorrhoea  and  generally  appears  in  pairs  or 
fours,  which  are  slightly  flattened  at  the  point 
of  contact.  It  may  be  very  beautifully  stained  in 
gonorrhceal  pus  with  a  weak,  watery  solution 
of  methylene  blue  when  the  organisms  are  seen 
in  or  on  the  pus  cells. 

This  disease  generally  begins  on  or  before  the 
third  day  after  birth,  and  is  particularly  prevalent 
182 


OPHTHALMIA   NEONATORUM.  183 

among  the  children  of  the  poor,  unclean,  and 
those  crowded  together.  The  eyelids  are  red  and 
swollen  and  painful  to  light,  and  the  pus  or  matter 
may  be  seen  oozing  under  the  closed  lids.  What 
makes  this  form  of  ophthalmia,  or  "  babies'  sore 
eyes,"  so  important  is  the  fact  that  it  is  one  of 
the  most  fruitful  causes  of  blindness. 

Thirty  per  cent,  of  all  inmates  of  blind  asylums 
in  Great  Britain  have  lost  their  sight  from 'this 
cause  alone,  and  71  per  cent,  of  all  who  lose 
their  sight  in  the  first  year  of  life,  and  23  per 
cent,  of  all  those  up  to  the  twentieth  year  who 
are  blind,  owe  this  blindness  to  ophthalmia 
neonatorum.  From  1870  to  1880  the  popula- 
tion of  the  United  States  increased  30  per  cent, 
while  blindness  in  the  United  States  in  this 
time  increased  140  per  cent.  The  only  proper 
treatment  of  this  condition  is  never  to  let  it 
occur,  and  while  this  may  not  be  possible, 
still,  the  number  of  cases  can  be  materially  de- 
creased by  careful  preventive  measures.  After  the 
disease  has  once  broken  out  it  comes  within  the 
province  of  the  physician  and  should  be  actively 
treated,  but  the  prophylactic  or  preventive  means 


184  HYGIENE   OF  THE  SICK-ROOM. 


should  be  familiar  to  the  nurse,  for  too  often,  by 
the  carelessness  of  the  nurse,  midwife,  or  even 
physician,  the  eyes  of  the  new-born  are  not 
looked  at  until  too  late.  The  self-confident  phy- 
sician is  not  unfrequently  the  cause  of  blindness. 

The  best  and  universally  adopted  method  of  de- 
creasing blindness  is  that  advocated  by  Crede.  He 
tried  different  means,  and  finally  settled  on  a  two 
per  cent,  solution  of  the  nitrate  of  silver,  one  drop 
of  which  should  be  dropped  into  each  eye  of 
every  child  born.  The  consequence  was  that  in 
the  institutions  of  which  he  had  charge  the  number 
of  these  cases  of  ophthalmia  neonatorum  decreased 
rapidly,  and  his  method  has  been  recommended 
to  all  those  who  deliver  women,  whether  in  public 
institutions  or  in  private  families.  While  it  is  not 
advisable  for  mothers,  nurses,  or  midwives  to 
use  Crede's  method  when  a  physician  can  be 
found,  yet  in  a  case  of  emergency,  when  the 
mother  of  the  new-born  child  is  known  to  be 
infected  with  gonorrhoea,  the  child's  eyes  should 
not  be  neglected. 

The  Medical  and  Chirurgical  State  Faculty 
of  Maryland,  appreciating  the  importance  and 


OPHTHALMIA   NEO  NATO  RUM.  185 

great  dangers  of  this  disease,  appointed  a  com- 
mittee, which  had  the  following  notice  printed 
in  large,  clear  type  on  a  card  10  by  14  inches. 
This  card  has  been  distributed  widely  and  is 
placed  conspicuously  in  every  public  place  where 
it  may  catch  the  eyes  of  those  interested : — 


WATCH  A  BABY'S  EYES  CAREFULLY  FOR 
A  WEEK  AFTER  BIRTH. 


If  they  look  Red,  or  Run  Matter,  take  it  at  once  to  a 
Doctor. 

THE  CHILD  MAY  BECOME  BLIND  IF  NOT 
TREATED  PKOPEELT. 


The  same  Committee  also  sent  the  following  cir- 
cular letter  to  every  midwife  in  Baltimore : — 

To  THE   MlDWIVES   OF   BALTIMORE  : 

The  undersigned  practicing  physicians  of  Baltimore  were 
appointed  by  the  Medical  and  Chirurgical  Faculty  of  Mary- 
land to  take  measures  tending  to  diminish  the  blindness  in 
our  city  and  State.  About  one-third  of  the  blind  in  our 
Blind  Asylums  have  lost  their  sight  through  a  disease  which 
is  common  among  the  newly-born.  This  fearful  disease, 
13 


1 86  HYGIENE   OF  THE  SICK-ROOM. 

which  causes  so  much  suffering  and  unhappiness,  can  often 
be  prevented  by  proper  care.  It  can  nearly  always  be  cured 
and  sight  saved  if  treatment  is  begun  early  and  kept  up. 
The  disease  shows  itself  by  redness  and  such  swelling  of 
the  eyelids  that  the  baby  cannot  open  its  eyes ;  the  eyes 
discharge  yellow  matter.  The  disease  usur.lly  begins  during 
the  first  few  days  of  life.  This  disease  /ill  often  cause 
incurable  blindness  in  forty-eight  hours  unless  properly 
treated. 

We  ask  you  to  impress  upon  the  mothers  you  attend  the 
great  danger  of  delaying  treatment.  Do  not  let  them  waste 
valuable  time  in  using  breast-milk,  chamomile  tea,  quince 
water,  and  other  home  remedies,  for  a  day  lost  may  rob  the 
infant  of  its  sight.  Insist  upon  sending  the  child,  as  soon 
as  the  disease  begins,  to  a  physician,  or,  if  the  parents  are 
unable  to  procure  one,  to  a  dispensary. 

You  can  do  much  toward  preventing  the  disease  by  thor- 
oughly cleansing  the  child's  eyes  immediately  after  it  is 
born.  Wash  the  eyes  carefully  with  fresh,  warm  water  and 
a  piece  of  perfectly  clean,  soft  linen.  Do  not  use  water  or 
linen  which  has  been  used  on  other  parts  of  the  body,  but 
wash  the  eyes  first  of  all.  You  will  assist  greatly  in  the  im- 
portant work  of  diminishing  blindness — 

1.  By  washing  the  eyes  of  the  newly-born  as  described 
above,  in  order  to  prevent  the  disease  from  attacking  them. 

2.  By  instructing  the  mothers  whom  you  attend  concern- 
ing the  importance  of  watching  the  eyes  closely  during  the 
first  and  second  week. 

3.  By  calling  attention  to  the  dangers  of  the  disease,  and 
the  great  urgency  of  prompt  medical  treatment. 


OPHTHALMIA   NEO  NATO  RUM.  187 


The  following  was  sent  to  each  physician  in  Bal- 
timore : — 

DEAR  DOCTOR: 

As  you  will  see  from  the  enclosed  circular  letter,  we  are 
making  an  effor*'to  impress  upon  the  midwives  in  our  city 
the  dangers  of  Ophthalmia  Neonatorum.  Our  Health  De- 
partment has  sent  a  copy  of  the  enclosed  to  each  midwife 
in  Baltimore.  In  this  work  we  ask  your  co-operation. 


CHAPTER  XIX. 

VENTILATION  AND  HEATING. 

Ventilation  is  one  of  the  most  important  and 
least  appreciated  factors  in  the  prevention  and  cure 
of  disease.  By  ventilation  we  not  only  replace  the 
impure  air  by  fresh  and  pure  air,  but  by  admitting 
this  fresh  air  we  dilute  the  number  of  disease 
germs  which  may  happen  to  be  present  in  any 
given  space. 

It  is  strange  that  so  many  in  all  occupations 
understand  to  a  small  extent  the  theory  of  ventila- 
tion, but  practically  ignore  it  absolutely.  It  is  not 
uncommon  to  see  a  body  of  physicians  in  scien- 
tific session  in  a  room  the  atmosphere  of  which  is 
almost  unbearable.  Many  public  halls,  even  in  this 
enlightened  age,  are  built  in  a  manner  aesthetically 
beautiful,  but  with  no  thought  to  ventilation.  Any 
one  who  has  felt  the  oppressive  effect  of  heavy  air 
will  readily  understand  why  a  collection  of  people 
in  one  of  these  halls  or  churches,  listening  to  a 
188 


VENTILATION  AND  HEATING.  189 


lecture  or  sermon,  is  often  so  sleepy  that  the  most 
eloquent  words  fail  to  impress  them. 

The  atmosphere  is  not  a  fixed  chemical  com- 
pound, but  a  mixture  containing  principally  nitro- 
gen, oxygen,  carbonic  acid  gas,  and  other  things,  as 
follows : — 

COMPOSITION  OF  ATMOSPHERIC  AIR. 

Oxygen, 209.6  per  1000  volumes 

Nitrogen, 790.0  "         " 

Carbonic  acid  (carbon  dioxide),        0.4  "         " 

Watery  vapor, Varies  with  the  tempera- 
ture. 
Ammonia, A  trace. 

Organic  matter  (in  vapor  or  sus-    ] 

pended,  organized,  dead  or 

living), 

Ozone, \  Variable. 

Salts  of  sodium, 

Other  mineral  substances,     .    .    .    J 

The  atmosphere  has  been  described  as  a  gaseous 
envelope  encircling  the  earth ;  an  ocean  of  air,  at 
the  bottom  of  which  we  live.  Under  ordinary 
circumstances  we  are  not  conscious  of  living  in 
this  atmosphere,  but  when  we  consider  that  the  air 
extends  upward  anywhere  from  50  to  200  miles 
above  sea  level,  it  is  evident  that  we,  at  the  bottom 
of  this  air  ocean,  must  be  subject  to  great  atmos- 
pheric pressure.  It  is  true  that  the  pressure  of  the 


igo  HYGIENE   OF  THE  SICK-ROOM. 

atmosphere  on  the  body  is  about  15  pounds  to  the 
square  inch  of  surface,  or  the  whole  body  supports 
a  weight  of  several  tons,  but  as  this  pressure  is 
equal  in  all  directions  it  is  not  noticeable.  It  is 
only  when  we  remove  the  pressure  on  one  side,  as 
in  the  experiment  of  exhausting  the  air  from  be- 
neath the  hand  by  an  air  pump,  that  we  appreciate 
this  great  pressure. 

As  water  normally  seeks  its  level  at  the  lowest 
point,  we  take  the  pressure  or  weight  of  the  atmos- 
phere at  sea  level  as  a  standard,  and  reckon  from 
this  point.  Torricelli  discovered  the  fact  that  the 
pressure  of  the  atmosphere  could  be  measured  by 
taking  a  glass  tube  sealed  at  one  end,  filling  it  with 
mercury,  and  inverting  it  by  placing  the  open  end 
covered  with  the  thumb  in  a  vessel  of  mercury. 
This  was  the  first  barometer.  The  column  of 
mercury  stood  at  about  30  inches  at  sea  level. 
The  density  or  weight  of  the  air  differs  at  different 
levels  ;  it  being  elastic  and  having  weight,  it  is  more 
compressed  below  and  lighter  above.  That  is,  the 
higher  we  ascend,  the  thinner  or  rarer  becomes 
the  atmosphere,  and  the  column  of  mercury  in  a 
Torricellian  barometer  stands  lower  and  lower  the 


VENTILATION  AND   HEATING.  191 

higher  we  ascend,  until  the  level  is  reached  beyond 
which  man  and  other  animals  cannot  live. 

Knowing,  then,  what  air  is  and  how  essential 
it  is  that  we  should  breathe  pure  air,  it  is  un- 
fortunate that  dwellers  in  cities  and  in  crowded 
communities  are  compelled  to  spend  most  of 
their  lives  in  impure  air.  Impurity  of  air  is 
directly  and  indirectly  one  of  the  most  usual 
causes  of  death.  The  air  may  be  composed  of 
its  proper  ingredients,  none  lacking  and  none  in 
excess,  and  yet  it  may  contain  impurities  in  the 
shape  of  vapors,  gases,  or  solid  particles.  Some 
of  these  can  be  detected  by  the  taste  or  smell, 
and  hence  cannot  do  harm  without  a  warning ; 
others  may  be  smelled  or  tasted  at  first  only,  but 
later  the  nerves  lose  their  delicacy  and  the  im- 
purity is  not  noticed. 

Fortunately,  the  atmosphere  is  not  an  immov- 
able mass.  Noxious  gases  are  diffused,  become 
diluted,  and  are  carried  away  by  currents  of  air; 
solid  particles,  in  time,  fall  to  the  ground  by  their 
own  weight,  or  are  washed  down  by  rains,  or 
plant  life  absorbs  the  impure  gases.  In  enclosed 
places  the  facts  are  far  different.  In  rooms  not 


1 92  HYGIENE   OF  THE  SICK-ROOM. 

perfectly  ventilated  and  inhabited  by  healthy 
persons  we  find  scaly  epithelium  from  the  mouth, 
fibers  of  cotton,  wool,  and  linen,  portions  of  food, 
bits  of  human  hair,  of  wood,  of  coal,  etc.  Green 
wall  paper  often  gives  off  little  particles  of  arsenical 
dust,  and  the  moisture  of  the  paste  on  green  wall 
paper,  especially  in  damp  weather,  may  cause  the 
diffusion  of  arseniuretted  hydrogen  in  the  room. 
This  has  been  brought  up  as  a  cause  of  poisoning, 
and  there  may  be  some  truth  in  this  supposition. 

In  rooms  occupied  by  sick  people,  particularly 
in  a  sickness  where  there  is  much  perspiration,  in 
addition  to  the  air  being  vitiated  by  respiration,  it  is 
contaminated  by  the  abundant  exhalations  from  the 
body  of  the  patient.  The  peculiar  and  unpleasant 
odor  from  these  exhalations  is  at  times  noticed  in 
the  best  hospitals,  and  physicians  have  claimed 
that  the  odor  of  certain  diseases,  as,  for  example, 
typhoid  fever,  is  pathognomonic. 

Looking  at  the  composition  of  the  air,  it  is  seen 
that  the  nitrogen  is  a  constant  ingredient,  while 
the  amount  of  oxygen  is  variable,  and  increasing 
the  amount  of  carbonic  acid  gas  means  less 
oxygen,  as  the  carbonic  acid  gas  is  formed  from 


VENTILATION  AND  HEATING.  193 

the  oxygen.  Animals  give  out  carbonic  acid  gas 
and  plants  exhale  oxygen.  In  considering  the 
impurities  in  the  air,  it  is  well  to  remember  that 
it  is  not  the  presence  alone  of  an  excess  of  car- 
bonic acid  gas  that  constitutes  bad  air,  but  also  a 
decrease  in  the  amount  of  oxygen,  together,  in 
many  cases,  with  the  products  of  respiration  and 
perspiration.  Indeed,  there  seems  to  be  great 
doubt  in  many  minds  as  to  what  bad  air  is.  It 
is  well  to  impress  the  fact  that  warm  air  is  not 
necessarily  impure,  nor  is  cold  air  always  pure, 
as  many  persons  seem  to  think. 

The  fact  that  the  excess  .of  carbonic  acid  gas  in 
the  atmosphere  does  not  constitute  impure  air  is 
partly  shown  by  the  fact  that  workers  in  certain 
trades,  as  in  brick  fields,  cement  works,  and  soda 
water  factories,  who  constantly  live  in  an  atmos- 
phere of  carbonic  acid  gas,  do  not  suffer  at  all. 
The  feeling  of  closeness  in  an  unventilated  room 
is  .due  more  to  the  want  of  oxygen  than  to  the 
excess  of  carbonic  acid  gas;  but  it  is  due  also, 
as  just  stated,  to  the  impurities  in  the  exhalations 
of  those  present.  The  carbonic  acid  gas  is  equally 
diffused  through  the  air  of  a  room  ;  it  is  very 


I94  HYGIENE   OF  THE  SICK-ROOM. 


easily  got  rid  of  by  opening  windows,  etc.,  while 
neither  organic  matter  nor  watery  vapor  diffuse 
rapidly  or  equally  through  a  room. 

The  impurity  of  air  is  often  caused  by  imperfect 
sewerage  and  drainage  systems.  Of  course,  one 
would  hardly  expect  to  find  pure  air  in  the  best 
cleaned  and  ventilated  sewers,  still,  the  air  of  the 
Berlin  sewers  has  been  said  at  times  to  be  entirely 
free  from  bacteria.  The  bad  air  of  sewers  is  caused 
by  the  mixture  of  excreta,  house-water,  debris 
from  streets,  factories,  etc.,  all  of  which,  being 
mixed  together,  undergoes  decomposition  and 
generates  such  impure  gases  as  sulphuretted  hy- 
drogen, etc.  Constant  flushing  of  sewers  will  tend  to 
carry  these  gases  off,  but  at  times,  when  the  atmos- 
phere is  heavy  and  when  there  are  backward  cur- 
rents of  air,  these  foul  gases  and  any  bacteria  which 
may  happen  to  be  present,  adhering  to  pieces  of  dust 
and  dirt,  are  drawn  back  into  houses,  dwellings,  etc. 

The  ideal  sewer  trap  in  dwelling  houses  and 
other  buildings  is  an  S-shaped  pipe,  which  is  always 
partly  filled  with  water  to  prevent  the  impure  air 
from  backing  up  into  the  houses,  but  this  does  not 
always  keep  out  the  gas.  This  is  particularly  true 


VENTILA  TION  AND  HEA  TING.  195 

of  a  house  which  has  been  unoccupied  for  some 
time  during  the  warm  season.  The  heat  causes 
the  water  in  the  S-shaped  pipe  to  evaporate,  and 
the  impure  sewer  gas  has  free  access  to  the  rooms 
and  soon  diffuses  through  the  whole  house.  The 
result  is  that  when  the  family  returns  and  the 
house  is  taken  again  there  is  probably  an  out- 
break of  some  disease,  such  as  typhoid  fever.  The 
actual  cause  is  rarely  thought  of  and  the  summer 
resort  is  usually  blamed  for  the  illness. 

The  air  of  all  towns  and  cities,  especially  where 
there  is  much  manufacturing  done,  is  particularly 
impure,  not  only  because  of  the  respiration,  com- 
bustion, etc.,  but  because  of  the  noxious  gases 
generated  by  these  factories.  As  plant  life  is 
largely  instrumental  in  absorbing  impure  gases,  it 
shows  the  necessity  of  having  a  certain  number  of 
parks  and  squares  scattered  throughout  the  city,  as 
well  as  the  importance  of  cultivating  trees  on  the 
streets.  There  are  many  occupations  which  are 
particularly  dangerous  on  account  of  the  impure 
air  which  they  cause.  For  example,  miners,  pot- 
ters, china  scourers,  grinders,  button  makers,  cut- 
lers, cotton,  wool,  and  silk  spinners  all  work  at 


196  HYGIENE   OF  THE  SICK-ROOM. 


trades  whigh  furnish  impurities  to  the  air.  These 
impurities  in  the  form  of  dust  are  inhaled  by  the 
respective  workers,  and  cause  various  lung  dis- 
orders of  a  chronic  and  often  fatal  nature.  There 
are  other  trades  in  which  certain  fumes  are  the 
chief  danger,  as  in  makers  of  matches,  painters, 
plumbers,  white  lead  workers,  workers  in  arsenic 
and  mercury,  gilders,  etc. 

Probably  the  best  known  example  of  an  unven- 
tilated  room,  the  one  most  familiar  to  us,  is  a  room 
in  which  the  air  has  been  rendered  impure  by 
respiration.  Such  air  usually  contains  organic 
matter  in  suspension,  such  as  epithelium,  hair, 
probably  some  bacteria,  never  free  but  always 
attached  to  dust  and  small  particles,  excess  of 
watery  vapor,  and  carbonic  dioxide.  This  pro- 
duces in  persons  heaviness,  headache,  weakness, 
and  it  may  be  nausea.  The  poisonous  element  in 
such  air  was  supposed  to  be  the  excess  of  CO2, 
but  from  experiments  on  animals  it  has  been  shown 
that  it  is  not  so  much  the  excess  of  CO2  in  the 
air  that  causes  these  ill  effects,  but  absence  of  the 
proper  amount  of  oxygen,  and  more  particularly 
the  excess  of  organic  matter  held  in  suspension. 


VENTILATION  AND  HEATING.  197 

The  large  number  of  deaths  in  the  Black  Hole  of 
Calcutta  was  caused  by  the  combination  of  all 
these  agencies,  and  the  few  survivors  of  this 
horrible  ordeal  felt  the  bad  effects  of  this  impure 
air  for  a  long  time.  George  Kennan's  graphic 
description  of  the  badly  ventilated  prisons  of 
Siberia  shows  to  what  tortures  the  Russian  pris- 
oners are  subjected,  and  much  of  their  suffering 
is  undoubtedly  due  to  the  forced  breathing  in  this 
vitiated  air. 

When  the  air  in  a  room  which  was  at  first  free 
from  impurities  becomes  gradually  worse,  the  oc- 
cupants do  not  notice  it  so  markedly  as  would  a 
person  coming  into  this  room  from  the  outer  air. 
The  latter  is  at  once  struck  with  the  unventilated 
odor  and  finds  it  unbearable.  It  is  usually  in 
certain  trades,  as  tailors,  shoemakers,  sewing 
women,  and  all  others  leading  a  sedentary  life, 
that  the  effects  of  the  slow  poisoning  are  noticed. 
Those  engaged  in  these  trades  just  mentioned,  as 
well  as  others,  come  to  their  morning  work  in 
a  room  fairly  well  aired  at  first.  There  they  sit, 
gradually  becoming  affected  by  the  air  growing 
hourly  heavier.  They  feel  tired  and  sleepy ; 


i98  HYGIENE   OF  THE  SICK-ROOM. 


they  yawn  frequently,  shQwing  that  the  lungs 
are  seeking  for  more  oxygen  to  take  to  the 
starving  blood.  Usually  such  persons  lead  this 
sedentary  life  and  remain  in  this  close  room 
and  constrained  position  for  hours  at  a  time. 
Such  persons,  too,  are  generally  underfed  and, 
it  may  be,  are  intemperate.  All  these  factors 
together  have  a  permanent  effect  on  the  system, 
and  the  most  common  result  is  pulmonary  disease, 
usually  consumption.  This  consumption  is,  of 
course,  not  caused  by  the  vitiated  air  and  sur- 
roundings, but  the  individual  is  put  into  a  favor- 
able condition  to  take  the  disease  if  exposed 
to  it,  and  the  extreme  prevalence  of  the  germ 
of  consumption  rarely  allows  them  to  escape. 
One  reason  why  such  persons  take  consumption 
so  easily,  is  because  their  power  of  respiration 
and  lung  expansion  from  this  constrained  position 
is  very  limited,  and  let  the  germ  of  consumption 
by  means  of  contaminated  dust  once  get  access 
to  the  lungs  by  being  breathed  in,  there  is  not 
enough  respiratory  force  present  to  get  rid  of  it, 
as  there  might  be  in  a  strong  and  healthy  chest. 
Air  in  a  room  may  be  too  rapidly  relieved  of  its 


VENTILATION  AND  HEATING.  199 


oxygen  by  the  burning  of  gas  jets.  While  candles 
and  oil  lamps  use  up  comparatively  little  oxygen, 
it  is  a  well-known  fact  that  gas  lights  exhaust  the 
supply  of  oxygen  very  quickly,  using  in  an  hour 
about  as  much  as  six  persons  in  the  same  time, 
and  they  give  the  air  in  such  a  room  a  dry,  un- 
comfortable feeling  without  necessarily  making -it 
as  impure  as  respiration  does.  The  connection 
between  bad  air  and  diarrhceal  diseases  is  par- 
tic'ularly  noticeable  in  children.  Of  course,  we 
believe  that  all  such  diseases  are  caused,  directly 
or  indirectly,  by  some  specific  germ,  but  the  im- 
pure and  heated  air  may  be  the  instigator.  Thus, 
so  much  has  been  said  about  the  normal  con- 
stituents of  pure  air  and  the  accidental  ingredients 
of  the  atmosphere,  because  it  is  now  well  recog- 
nized that  the  air,  with  its  varying  changes  in 
composition,  density,  temperature,  humidity,  rate 
of  motion,  and  other  conditions,  influences  for 
good  or  evil  the  health  of  the  individual.  The 
individual  uses  the  oxygen  and  gives  out  car- 
bonic dioxide,  which  is  at  once  taken  up  by 
the  plants,  which  use  the  carbon  dioxide  and 
liberate  the  oxygen,  to  be  again  used  by  animals. 


200  HYGIENE   OF   THE  SICK-ROOM. 


Thus  this  interesting  interchange  of  gases  goes 
on  and  the  balance  of  gases  in  the  atmosphere 
is  kept  up.  Through  the  diffusion  of  gases  and 
currents  of  air  the  atmosphere  is  of  about  the 
same  consistency  everywhere.  The  heavy  carbon 
dioxide  has  a  tendency  to  sink,  and  the  lighter 
oxygen  to  rise,  but  by  diffusion  these  two  gases 
intermingle. 

Now,  having  considered  the  composition  of  the 
air,  it  would  be  well  to  look  at  our  means  of  sup- 
plying pure  air  to  closed  habitations,  particularly 
to  large  buildings,  as  hospitals,  halls,  etc.  Of 
course,  in  the  open  air  there  are  always  currents  of 
air  and  breezes  caused  by  the  difference  of  pressure 
and  temperature  of  different  parts  of  the  atmos- 
phere. In  this  way  breezes  and  winds  are  caused 
which  purify  the  air  by  blowing  away  and  diluting 
noxious  gases  and  impurities  in  the  air.  The  air 
in  every  inhabited  room  should  be  pure  enough 
not  to  cause  an  odor  which  may  be  perceived  by 
one  coming  from  the  outer  air  into  the  room.  The 
sense  of  smell  is  the  most  convenient  standard. 
One  way  to  look  for  an  excess  of  carbonic  acid  gas 
in  a  room  is  to  expose  a  vessel  containing  ordinary 


VENTILATION  AND  HEATING.  201 


lime  water  to  the  air  of  the  room,  when  the  carbonic 
acid  gas  will  cause  a  cloudiness  in  the  lime  water 
to  appear.  The  idea  of  ventilation  is  to  supply 
fresh  for  impure  air,  to  flush  out  the  emanations 
from  the  skin,  breath,  etc.,  and  dilute  any  impuri- 
ties, whether  germs  or  otherwise,  in  the  air. 

Dr.  Wm.  H.  Welch  in  a  recent  article  says : — 
"  By  means  of  free  ventilation,  disease-producing 
micro-organisms  which  may  be  present  in  the  air 
of  rooms  are  carried  away  and  distributed  so  far 
apart  that  the  chance  of  infection  from  this  source 
is  removed  or  reduced  to  a  minimum.  It  is  a  well- 
established  clinical  observation  that  the  distance 
through  which  the  specific  microbes  of  such 
diseases  as  small-pox  or  scarlatina  are  likely  to  be 
carried  from  the  patient  by  the  air,  in  such  con- 
centration as  to  cause  infection,  is  small,  usually 
not  more  than  a  few  feet,  but  increases  by  crowding 
of  patients  and  absence  of  free  ventilation.  The 
well-known  experiences  in  the  prophylaxis  and 
treatment  of  typhus  fever  are  a  forcible  illustration 
of  the  value  of  free  ventilation. 

"  It  is,  of  course,  not  to  be  understood  that  by 

ventilation   we   accomplish   the  disinfection    of  a 
14 


202  HYGIENE   OF  THE  SICK-ROOM. 

house  or  apartment.  Ventilation  is  only  an  adjunct 
of  such  disinfection,  which,  as  already  mentioned, 
is  of  first  importance." 

This  change  of  air  should  take  place  so  gradu- 
ally that  it  is  not  perceptible.  That  is,  there 
should  be  a  constant  stream  of  warmed  pure  air 
passing  through  the  room  so  slowly  that  it  is  not 
perceptible.  The  principles  of  ventilation  depend 
on  the  fact  that  air  when  heated  tends  to  expand, 
and  by  expanding  escapes  through  the  cracks  of 
the  buildings  and  through  the  porous  walls.  This 
expansion  causes  a  partial  vacuum,  which  is 
quickly  filled  by  the  cool,  fresh  air  drawn  from 
without,  so  that  one  of  the  best  ways  of  furnishing 
fresh  air  to  a  room  is  to  make  a  hot  fire  in  it,  when 
the  warmed  air  will  expand  and  draw  in  the  cool 
air  from  the  outside  through  the  porous  walls  and 
cracks  in  the  doors  and  windows.  Another  simple 
method  of  ventilation  is  to  have  an  open  fire,  which 
causes  a  steady  current  of  air  to  pass  through  the 
room  and,  by  the  heat  of  the  fire,  up  the  chimney. 
The  carbon  dioxide  being  heavy,  it  would  be  sup- 
posed that  it  would  sink  to  the  floor,  but  in  reality 
this  is  not  so ;  for  the  diffusion  and  the  varied 


VENTILA  TION  AND  HEA  TING.  203 


currents  of  air  cause  it  to  be  scattered  through  the 
room,  and,  in  fact,  the  heated  air  is  apt  to  rise  to 
the  ceiling  and  carry  the  carbon  dioxide  with  it. 

The  more  difficult  problem  of  ventilating  a 
hospital  has  not  yet  been  satisfactorily  solved. 
The  simplest  method  is  to  have  a  shaft  below  near 
the  floor,  through  which  cold_air  can  enter,  and  a 
shaft  above  ne^r  the  ceiling,  through  which  warm 
and  impure  air  can  escape.  In  order  to  do  this 
without  creating  a  strong  draught,  the  shaft  above 
should  not  be  immediately  over  the  shaft  below. 
When  the  ventilating  current  is  feeble  and  not 
strong  enough  to  remove  the  used  air,  a  lighted  gas 
jet  in  the  upper  ventilator  will  heat  the  shaft,  and 
the  expansion  thus  caused  will  remove  the  air 
more  quickly. 

The  two  methods  of  ventilation  are  the  natural 
and  artificial.  In  natural  ventilation  we  have  three 
forces  at  work,  namely,  diffusion,  winds,  and  the 
difference  of  weight  of  masses  of  air  of  unequal 
temperature.  Diffusion  takes  place  in  every  room 
that  is  not  air-tight.  It  occurs  through  brick  and 
stone,  especially  when  they  are  dry,  and  for  this 
reason  a  newly  built  house  with  fresh,  damp  walls 


204  HYGIENE   OF   THE  SICK-ROOM. 


is  unhealthy,  because  diffusion  cannot  take  place 
through  these  walls.  Of  course,  this  diffusion  is 
not  sufficient  for  perfect  ventilation,  but  it  helps. 
The  wind  can  only  be  used  in  part  to  ventilate 
rooms.  It  blows  the  stagnant  stale  air  out,  and  by 
causing  a' partial  vacuum  draws  in  purer  air  behind 
it.  By  blowing  over  the  tops  of  chimneys  and 
shafts  the  wind  draws  by  suction  the  bad  air  from  a 
room  or  building  and  purer  air  is  drawn  in  through 
the  cracks  caused  by  imperfect  carpenter  work. 
Ventilation  by  aspiration  is  used  principally  on 
board  ship  and  in  large  halls.  The  ventilation  by 
unequal  weights  of  air  is  illustrated  in  the  heated 
room,  as  explained  above.  The  heated  air  expands 
so  that  a  portion  of  it  escapes.  To  compensate 
for  this,  purer  air  is  drawn  in  through  the  walls, 
cracks,  etc.,  and  this  in  turn  is  heated,  and  so  on 
in  this  way  the  air  is  kept  changing. 

In  artificial  ventilation  the  used  air  is  either 
drawn  out  of  a  building  (method  of  extraction),  or 
the  fresh,  purer  air  is  forced  in  (method  of  propul- 
sion). These  methods  are  used  in  mines,  mills, 
factories,  and  large  halls.  The  ways  of  testing 
these  methods  are  very  complicated.  They  are 


VENTILATION  AND  HEATING.  205 

principally  by  determining  the  amount  of  space, 
the  number  of  people,  and  how  much  air  each  one 
requires,  as  well  also  as  examining  the  air  by  the 
senses,  by  chemical  and  microscopical  means. 

The  system  of  ventilation  used  in  one  of  the 
most  carefully  built  hospitals  in  this  country,  and 
it  may  be  in  the  world,  is  supposed  to  be  as  near 
perfect  as  possible.  Whether  all  the  theories  of 
ventilation  as  used  in  the  Johns  Hopkins  Hospital 
in  Baltimore  have  come  up  practically  to  the 
expectations  and  plans  of  those  who  began  and 
finished  this  great  work,  it  is  not  easy  to  find  out. 
The  following  quotation  from  the  description  of 
the  Johns  Hopkins  Hospital  will  give  a  fair  idea 
of  the  methods  of  ventilation  used  in  that  in- 
stitution. 

"  The  extent  of  external  temperatures  in  Balti- 
more have  a  range  from  102°  F.  in  summer  to 
six  degrees  below  zero  F.  in  winter,  these  extremes 
occurring  about  once  in  ten  years.  To  provide  for 
these  extremes  requires  buildings  and  apparatus 
.which  would  be  satisfactory  in  either  Calcutta  or 
St.  Petersburg. 

"  Let    us   first   consider   the   arrangements    for 


206  HYGIENE   OF  THE  SICK-ROOM. 


ventilation  in  cold  weather.  In  the  wards  and 
rooms  occupied  by  the  sick,  the  sizes  of  flues  and 
registers  and  the  amount  of  heating  surface  have 
been  arranged  for  a  supply  of  one  cubic  foot  of 
fresh  air  per  second  for  each  person  in  the  ward, 
with  the  possibility  of  doubling  the  supply  for  a 
short  time  in  flushing  out  the  ward,  as  will  be 
presently  explained.  In  the  pay  wards,  where 
each  patient  has  a  separate  room,  making  it  more 
difficult  to  secure  thorough  distribution,  the  supply 
of  air  is  to  be  one  and  a  half  cubic  feet  per  second 
per  head.  In  the  isolating  ward,  designed  for 
cases  giving  rise  to  offensive  odors  or  in  which  a 
large  amount  of  organic  matter  is  thrown  off,  or  in 
which,  for  other  reasons,  a  large  amount  of  air  is 
desirable,  the  air  supply  is  fixed  at  two  cubic  feet 
per  second  per  head.  Finally,  three  rooms  in 
the  isolating  ward  are  arranged  with  perforated 
floors  for  an  air  supply  of  four  cubic  feet  per 
second  per  head,  with  capacity  for  doubling  this 
if  desired.  For  all  the  wards  the  air  is  warmed  in 
cold  weather  before  it  is  admitted  to  the  room,, 
forming  the  so-called  method  of  heating  by  indi- 
rect radiation  or  by  air  convection. 


VENTILATION  AND  HEATING,  207 

"  All  registers  and  flues  for  fresh  air  are  of  such 
sizes  as  to  permit  the  passage  of  the  requisite 
amount  of  air  with  a  velocity  not  exceeding  one  and 
a  half  feet  per  second  under  ordinary  circum- 
stances. Air  currents  of  this  velocity  having  a 
temperature  of  from  70°  to  75°  F.,  are  barely 
perceptible  by  the  hand,  and  create  little  or  no 
discomfort.  The  fresh  air  registers  are,  as  a  rule, 
placed  in  the  piers  in  the  outer  walls  at  a  height  of 
nine  inches  from  the  floor,  one  register  being 
allowed  to  each  pair  of  beds.  Besides  these  there 
are  registers  beneath  the  windows  in  the  wards, 
which  are  only  used  in  very  cold  weather,  to  check 
the  down  draughts  produced  by  the  chilling  of  the 
air  through  the  glass  of  the  window.  The  chief 
register,  being  that  in  the  pier  between  each  pair  of 
beds,  is  so  arranged  that  the  nurse,  by  turning  an 
iron  arm  upon  its  face,  can  reduce  the  temperature 
of  the  incoming  air  nearly  to  that  of  the  external 
air,  or  can  increase  it  to  the  maximum  which  the 
heating  coil  affords,  but  without  changing  the 
quantity  of  the  air  admitted. 

"  Ordinarily,   as   is    well    known,  when  a    room 
heated    by    indirect   radiation  becomes  too  warm, 


208  HYGIENE   OF   THE  SICK-ROOM. 


the  only  way  to  shut  off  the  heat  supply  is  to 
close  the  register  and  thus  shut  off  the  air 
supply  also,  but  in  these  wards  the  temperature 
can  be  regulated  at  the  different  registers,  in 
different  parts  of  the  room,  to  suit  the  needs  of 
different  patients,  without  interfering  with  the  air 
supply." 

The  heating  of  private  houses  and  public  build- 
ings is  a  matter  deserving  of  more  notice  than  it 
often  receives.  In  so  many  cases,  especially  among 
the  poorer  classes,  the  proper  temperature  is 
maintained  by  keeping  the  rooms  closed,  and,  as  in 
some  stables,  depending  on  the  animal  heat.  Of 
course,  while  this  may  keep  up  the  proper  temper- 
ature when  the  weather  is  not  too  cold,  it  does  so 
at  the  expense  of  the  air.  Experience  has  shown 
that  the  proper  temperature  for  rooms  is  from  65° 
to  70°  F.,  and  in  many  cases  higher.  The  strong, 
the  young,  and  the  well  do  not  usually  need  a  high 
temperature,  but  children,  the  feeble,  and,  indeed,  all 
at  the  extremes  of  life  need  a  higher  temperature. 

The  principal  methods  of  heating  are  by  open 
fireplace,  by  stoves,  by  furnace  and  hot-air  pipes, 
by  hot  water,  and  by  steam.  In  America  we  are 


VENTILA  TION  AND  HE  A  TING.  209 


supposed  to  like  overheated  rooms.  This  may  be 
a  bad  habit  or  it  may  be  due  to  our  climate. 

Mr.  Frederick  N.  Owen  in  the  American  Ap- 
pendix to  Parkes'  "Hygiene"  says:  —  "Those 
accustomed  to  a  daily  heat  of  70°  to  100°  F.  in 
summer,  may  perhaps  become  less  capable  of  re- 
sisting cold  in  winter.  It  is  also  a  fact  that  most 
parts  of  our  country  possess  a  drier  atmosphere 
than  that  of  England  and  Western  Europe,  and 
that  moisture  acts  as  a  protective  against  the  loss 
of  bodily  heat ;  hence  an  American  room  in  win- 
ter, with  a  dry,  hot  air  (70°  F.),  may  appear  to  its 
occupants  no  warmer  than  an  English  room  with 
a  moister  air  at  65°  F.,  or  even  at  a  lower  point." 

A  few  points  may  be  learned  from  the  apparatus 
at  the  Johns  Hopkins  Hospital.  All  the  wards  and 
much  of  the  hospital  are  heated  by  a  system  of 
circulation,  through  iron  pipes,  of  hot  water  of 
comparatively  low  temperature  and  pressure.  In 
many  of  the  rooms  there  are,  in  addition  to  this, 
open  fireplaces.  A  few  rooms  are  heated  by 
steam.  From  the  boilers  the  heated  water  passes 
into  the  great  outflow  main  and  from  this  into  the 
smaller  mains  and  from  these  to  the  pipes  in  the 


210  HYGIENE   OF  THE  SICK-ROOM. 


heating  coils.  The  heat  being  supplied  to  the 
rooms,  the  cooled  water  is  returned  to  the  boiler 
to  be  heated  and  used  again. 

"  This  circuit  is  practically  a  closed  one,  none  of 
the  water  being  drawn  off  or  used  at  any  point, 
so  that  there  is  very  little  loss.  The  force  which 
produces  this  circulation  is  a  small  one,  being  the 
difference  in  weight  of  a  column  of  heated  water 
from  that  of  a  similar  column  of  water  of  from  8° 
to  15°  F.  lower  temperature,  each  column  being 
about  29  feet  high,  which  is  the  difference  be- 
tween the  level  of  the  water  in  the  boilers  and 
that  of  the  top  of  the  heating  coils.  By  means 
of  valves  on  all  the  mains,  and  on  the  supply  and 
the  discharge  pipe  to  each  coil,  the  rapidity  of  the 
circulation  can  be  controlled  for  each  building  and 
for  each  coil,  thus  giving  a  corresponding  control 
over  the  temperature  of  the  coils  themselves,  since 
this  is  dependent  on  the  amount  of  water  of  a 
given  temperature  which  passes  through  the  coil 
in  a  given  time. 

"  The  entire  system  of  hot  water  heating  at  the 
Johns  Hopkins  Hospital  contains  about  175,000 
gallons  of  water,  and  practical  trial  has  shown  that 


VENTILA  TION  A  ND   HE  A  TING.  2 1 1 


it  produces  an  equable,  agreeable  temperature  in 
all  the  buildings  to  which  it  is  applied,  in  all  con- 
ditions of  cold  weather,  and  with  the  fullest  venti- 
lation desired.  To  prevent  loss  and  waste  of  heat 
in  the  pipe  tunnel  and  in  the  basements  of  the 
several  buildings,  the  pipes  are  covered  with  felt 
enveloped  in  asbestos  paper,  and  the  whole  is  en- 
closed with  stout  canvas  thoroughly  painted.  The 
effect  of  this  protection  is  marked  and  satisfactory 
— very  little  heat  is  lost,  as  is  shown  by  the  tem- 
peratures in  the  pipe  tunnel,  and  a  great  saving  of 
fuel  is  thus  effected.  The  heating  coil  most  distant 
from  the  boiler  is  763  feet  away. 

"  The  great  advantage  of  this  system  of  heating 
for  rooms  constantly  occupied  by  the  sick  in  the 
climate  of  Baltimore  are  :•  its  uniformity  of  action, 
the  comparatively  low  temperature  of  the  heating 
surface  over  which  the  air  is  passed,  the  ease  with 
which  different  temperatures  may  be  secured  in 
different  rooms,  or  even  for  different  beds  in  the 
same  room,  and,  above  all,  that  it  insures  the 
delivery  of  a  large  supply  of  air  heated  to  the 
temperature  required  for  comfort  without  the  risk 
of  overheating  or  of  sudden  changes." 


212  HYGIENE   OF  THE  SICK-ROOM. 


The  heating  of  certain  rooms  not  in  constant 
use,  and  in  which  it  was  desirable  to  have  the 
means  of  raising  the  temperature  in  them  more 
rapidly  than  could  be  done  by  the  circulation  of 
hot  water,  is  effected  by  low  pressure  steam  heat. 


CHAPTER  XX. 

IMMUNITY   AND   PROTECTION   FROM    DISEASE. 

And  now,  having  considered  some  of  the  prin- 
cipal causes  of  disease,  and  having  shown  how 
universally  scattered  about  disease  germs  are,  it 
naturally  suggests  to  ask  why  we  do  not  all  have 
every  disease  and  what  protects  us  when  we 
escape. 

We  know  that  it  is  possible  to  have  bacteria  in 
some  form  in  the  water  which  we  drink  and  use, 
in  our  food,  on  things  we  touch,  in  the  air  we 
breathe ;  indeed,  there  seems  to  be  no  place 
within  our  reach  where  it  is  not  possible  for 
bacteria  to  be  found  at  some  time.  If  disease, 
then,  is  present  in  so  many  forms  and  so  univer- 
sally, it  seems  wonderful  that  so  many  escape. 

There  are  several  theories  as  to  immunity  and 
protection  from  disease,  and  while  many  of  them 
come  near  the  probable  truth,  none  of  them 
are  entirely  satisfactory ;  still,  even  at  the  risk 
of  indulging  in  theories  in  a  book  supposed  to 
213 


214  HYGIENE   OF   THE  SICK-ROOM. 

be  practical,  the  principal  explanations  of  these 
conditions  must  be  given  to  complete  the  subject. 

Dr.  A.  C.  Abbott,  of  Philadelphia,  in  a  recent 
article  in  the  Philadelphia  Medical  News,  in  re- 
viewing the  principal  experimental  work  that 
has  been  contributed  to  the  subjects  of  im- 
munity and  infection  in  the  past  few  years,  says: 
"Until  the  year  1888  there  existed  four  different 
doctrines  by  which  the  condition  of  acquired 
immunity  against  infection  could  be  accounted 
for.  The  first  of  these  theories  suggests  that 
the  immunity  commonly  seen  to  exist  in  animals 
that  had  passed  through  an  attack  of  infection 
against  a  subsequent  outbreak  of  the  same 
malady,  and  likewise  the  immunity  that  had 
been  produced  artificially,  exists  by  virtue  of 
some  bacterial  product  that  has  been  retained  in 
the  tissues  of  those  animals,  and  that  by  its 
presence  prevents  the  development  of  the  same 
organisms  when  they  subsequently  gain  access 
to  the  body.  This  is  the  so-called  '  retention 
hypothesis.' 

"  On  the  other  hand,  Pasteur  and  certain  of 
his  pupils  believed  that  the  resistance  frequently 


IMMUNITY  FROM  DISEASE.  215 

afforded  to  the  tissues  by  an  attack  of  infection, 
following  upon  vaccination  against  infection,  was 
due  rather  to  an  abstraction  from  the  tissues, 
by  the  organisms  that  were  concerned  in  the 
primary  attack,  of  a  something  that  is  necessary 
to  the  growth  of  the  organism  should  it  gain 
entrance  to  the  body'at  a  subsequent  time.  This 
view  is  known  as  the  '  exhaustion  hypothesis.' 

"In  1884,  Metschnikoff  published  the  first  of 
a  series  of  observations  upon  the  relation  that 
is  seen  to  exist  between  certain  of  the  cells  of 
the  lower  animals  and  insoluble  particles  that 
may  be  present  in  the  tissues  of  these  animals." 

This  theory,  which  is  both  fascinating  and 
plausible,  is  set  forth  in  the  following  article 
published  in  the  Philadelphia  Medical  News  some 
time  ago  by  the  author : — 

"  When  a  physician  attempts  to  cure  disease 
he  simply  removes,  as  far  as  possible,  the  cause, 
clears  the  way  to  recovery,  and  lets  Nature  do 
the  rest.  In  many  cases  Nature  does  her  work 
well,  although  not  always  getting  due  credit 
for  warding  off  disease  and  protecting  us  from 
harm ;  in  other  cases  she  succumbs  to  her 


216  HYGIENE   OF  THE  SICK-ROOM. 


stronger  foe — Disease.  Those  of  us  who  live  in 
crowded  communities  are  surrounded  by  an  in- 
visible enemy,  and  with  every  breath  we  are 
liable  to  draw  in  disease  in  some  form — and  yet 
so  many  escape.  We  open  our  windows  and  let 
in  what  we  call  '  fresh  air/  and  as  the  sunbeam 
slants  across  the  room,  what  myriads  of  dusty 
atoms  meet  our  eyes !  If  in  a  quiet  room  we 
inhale  at  every  breath  this  dust,  what  would  we 
not  .breathe  in  the  streets  of  dusty  cities,  in  mines, 
and  in  mills  ? 

"  In  the  sanitary  management  of  our  cities,  the 
danger  of  flying  dust,  with  its  many  impurities,  is 
rarely  considered,  and  the  dust  of  city  streets,  that 
should  be  properly  sprinkled  and  carted  away, 
is  simply  stirred  up  by  the  indolent  sweepers  and 
much  of  it  is  probably  taken  away  in  the  clothes 
and  breathing  apparatus  of  the  unfortunate  passers- 
by.  Such  dust,  when  inhaled,  does  harm  both 
from  the  impurities  it  may  contain,  and,  when 
present  in  appreciable  quantity,  from  its  mechanical 
action  and  irritation. 

"  That  germs  float  in  the  air,  even  in  the  most 
secluded  spot,  the  careless  housewife  knows  to  her 


IMMUNITY  FROM  DISEASE.  217 

sorrow  when  she  leaves  her  jelly-glasses  uncovered 
for  a  short  time  an.d  finds  the  surface  covered  with 
a  beautiful  mould.  Bacteriology  has  told  us  that 
the  germs  of  some  contagious  diseases  are  found 
in  the  air  and  may  be  inhaled  and  produce  disease. 
Thus  diphtheria,  glanders,  measles,  whooping- 
cough,  hay-fever,  pneumonia,  and  consumption  are 
all  undoubtedly  in  part  due  to  the  inhalation  of 
dust  containing  the  germs  of  these  diseases.  If, 
then,  the  germs  of  disease  are  in  so  many  forms 
floating  in  the  air,  it  is  strange  indeed  that  so 
many  escape,  especially  when  we  consider  the 
crowded  public  and  private  rooms,  cars,  and  other 
places  where  the  sick  and  well  meet  together  and 
breathe  the  same  air. 

"  Fortunately  for  us,  Nature  has  erected  a 
series  of  barriers  against  such  an  enemy  as  in- 
spired dust,  and  in  exposing  us  to  this  danger,  has 
given  us  certain  means  of  protection  that  repels 
attacks  not  unusually  severe. 

"  In  persons  who  breathe  as  they  should,  all 
inspired  air  passes  first  through  the  nostrils,  and  is 
thus  not  only  warmed  to  the  proper  temperature 
for  the  throat  and  lungs,  but  the  moist  walls  serve 


218  HYGIENE   OF  THE  SICK-ROOM. 


as  a  sieve  by  which  the  air  thus  inhaled  is  as  far  as 
possible  relieved  of  dusty  impurities.  This  shows 

• 

at  once  the  importance  of  breathing  with  closed 
mouth,  especially  in  passing  from  a  heated  to  a 
cooler  atmosphere,  and  of  always  thus  breathing 
in  an  atmosphere  of  visible  dust.  The  moist 
walls  of  the  lining  membrane  of  the  nasal  cavities 
fill  the  inspired  air  with  moisture,  thus  making  it 
more  agreeable  to  the  throat  and  lungs. 

"  The  nasal  passage  in  almost  every  animal 
deviates  from  a  straight  channel,  and  this  is  ac- 
cording to  the  needs  of  the  animal.  In  man,  who 
is  upright  and  far  from  the  ground,  the  passage  is 
only  slightly  curved  and  may  almost  be  considered 
rudimentary  in  its  development.  In  birds,  which 
fly  far  above  the  earth,  the  nasal  passage  is  almost 
straight  In  all  quadrupeds,  and  especially  in 
those  that  graze  or  seek  their  food  on  the  ground, 
and  those  exposed  to  sudden  changes  of  tempera- 
ture, as  in  amphibious  animals,  the  nasal  passages 
are  exceedingly  tortuous  and  in  a  high  state  of 
development,  and  their  extreme  moisture,  due  to 
the  active  secretion  of  their  lining  mucous  mem- 
branes, serves,  as  far  as  possible,  to  catch  and  stop 


IMMUNITY  FROM  DISEASE.  219 


the  entrance  of  dust  into  the  throat  and  lungs.  This 
is  familiar  to  us  in  the  cold  nose  of  the  dog,  cow, 
etc.,  and  in  the  constant  sneezing  of  the  horse. 

"  Those  who  breathe  abnormally,  with  open 
mouth,  are  much  more  liable  than  others  to 
diseases  of  the  throat  and  lungs.  In  spite  of  the 
outward  defense  we  have  in  the  nose,  dust  and 
foreign  substances  do  occasionally  get  into  the 
throat  and  trachea,  but  the  latter  is  so  very  sen- 
sitive to  the  slightest  irritation  that  the  presence  of 
such  foreign  substances  excites  a  cough,  and  they 
are  quickly  expelled.  The  minute  anatomical 
structure  of  the  lining  membrane  of  the  trachea 
is,  as  we  know,  much  like  the  waving  surface  of  a 
wheat-field.  The  whole  surface  of  the  trachea 
and  larger  lung-tubes  is  covered  with  ciliated  epi- 
thelium the  waving  motion  of  which  is  from  the 
lungs  upward  to  the  throat,  and  very  minute  par- 
ticles of  dust  and  foreign  substances  that  find 
their  way  into  this  region  are  thus  gradually 
removed.  This  membrane  is  also  active  during 
sleep,  as  many  throat  sufferers  and  others  may 
have  noticed  from  the  fact  of  their  '  morning 
cough '  on  rising. 


220  HYGIENE   OF  THE  SICK-ROOM. 

"  In  spite  of  these  defenses  which  Nature  has 
raised  against  her  enemies,  disease  germs  and 
foreign  substances  find  their  way  into  the  trachea 
and  even  to  the  ultimate  ends  of  the  finest  lung- 
tubules.  In  this  way  disease  germs,  and  especially 
the  tubercle  bacilli,  get  into  the  lungs,  and  in  those 
predisposed  to  this  disease  this  organism  easily 
thrives.  From  recent  investigations  in  microsco- 
pical anatomy  we  now  know  that  Nature  does  not 
give  up  even  after  these  foreign  substances  and 
disease  germs  find  a  place  in  the  body. 

"  In  the  organism,  and  more  particularly  in  the 
blood,  there  has  long  been  known  a  cell  or  cor- 
puscle called  the  white  blood-corpuscle,  or  leu- 
cocyte, and  in  suppuration  the  same  cell  is  recog- 
nized as  the  pus  cell.  That  this  cell  seems  almost 
ubiquitous  in  the  body,  and  that  it  assumes  different 
roles  under  different  circumstances,  has  also  been 
the  subject  of  repeated  investigation.  The  most 
recent  function  now  assigned  to  this  cell  is  that  of 
a  "  carrier  cell,"  scavenger  cell,  or  phagocyte, 
because  its  function  has  been  learned  to  be  that  of 
devouring  or  carrying  off  germs  and  foreign  sub- 
stances. This  was  noticed  in  those  who  worked  in 


IMMUNITY  FROM  DISEASE.  221 

dusty  atmospheres.  The  dust  was  inhaled  in  such 
quantities  that  it  got  into  the  lungs,  and,  as  it 
could  not  all  be  coughed  up,  it  worked  its  way 
into  the  lung  substance,  where,  by  irritation,  it 
attracted  these  carrier  cells  or  scavengers,  and,  as 
far  as  possible,  these  promptly  attacked  the  parti- 
cles and  carried  them  either  to  the  nearest  lym- 
phatic gland,  where  they  would  be  quiet  and 
harmless,  or  the  dust-containing  cells  found  their 
way  into  the  lungs  and  were  coughed  up.  This 
has  been  repeatedly  noticed  in  the  case  of  coal 
miners,  in  whose  expectoration  large  numbers  of 
these  cells  were  found,  and  in  those  cells  bits  of 
coal  dust  could  be  easily  recognized.  In  some 
cases  in  which  the  piece  of  dust  was  too  large  for 
one  cell  to  devour,  two  or  more  would  join 
together  and  close  around  it. 

"These  cells  have  certain  movements,  called 
amoeboid,  from  their  resemblance  to  the  move- 
ments of  the  amceba,  one  of  the  lowest  forms  of 
life,  and  found  on  the  surface  of  fresh-water  ponds. 
These  amoeboid  movements  consist  in  a  change  of 
shape  on  the  part  of  the  cell  by  which  it  thrusts 
out  a  part  on  one  side  and  draws  in  another  part, 


222  HYGIENE   OF  THE  SICK-ROOM. 


and  by  thus  changing  its  shape  it  surrounds  the 
substance  and  assimilates  it.  These  movements, 
however,  are  so  slow  that  they  cannot  be  seen, 
much  like  the  moving  of  the  minute  hand  of  a 
clock  or  watch ;  a  change  is  noticed  on  making  in- 
termittent observations,  but  the  actual  movement 
cannot  be  seen.  That  these  cells  endeavor  to  do 
their  work  as  well,  as  possible  is  shown  by  the 
fact  that  years  after  miners  have  ceased  to  work  in 
coal  mines  it  has  been  noticed  that  the  expecto- 
ration remained  dark,  and  a  microscopical  exami- 
nation showed  these  cells  to  be  full  of  coal  and 
pigment,  thus  proving  that  the  carrier  cells  were 
still  trying,  as  far  as  possible,  to  remove  the  for- 
eign substances.  This  has  been  experimentally 
demonstrated  by  introducing  finely  divided  or- 
ganic substances,  such  as  powdered  cinnabar,  into 
the  tissues  and  lungs  of  the  animal,  and  after  a 
short  time  microscopically  examining  the  tissues 
and  glands  of  the  animal,  when  these  carrier  cells 
are  found  loaded  down  with  this  red  pigment. 
This  is  especially  true  of  the  cells  in  the  glands. 

"  In  all  these  cases  the  role  of  the  foreign  sub- 
stance is  undoubtedly  passive,  while  the  cell  is  active. 


IMMUNITY  FROM  DISEASE.  223 

Further  study  of  these  cells  showed  that  they  act 
antagonistically  to  pathogenic  bacteria — that  be- 
tween these  cells  and  the  bacteria  there  is  a  struggle 
for  existence  or  supremacy,  and  on  the  result  of  the 
struggle  depends  a  condition  of  illnass  or  health. 
These  observations  were  first  made  on  a  disease 
produced  by  a  fungus  in  a  fresh-water  crustacean, 
the  daphnia,  a  '  water  flea.'  The  fungus  swallowed 
by  the  crustacean  produces  spores  that  pierce  the 
intestinal  wall,  enter  into  the  tissues,  and  are  at 
once  surrounded  by  these  phagocytes.  Here  a 
struggle  takes  place  that  results  in  a  victory  for 
the  cells,  the  latter  closing  around  these  fungus 
spores,  devouring  them  and  finally  destroying 
them  by  a  process  of  '  intra-cellular  digestion.'  In 
this  case  the  action  is  very  simple,  but  in  the 
case  of  other  animals  and  man  it  is  not  so  simple. 

"  A  careful  study  of  these  bacteria,  both  biolog- 
ical and  chemical,  has  fully  proved  that  they  exert 
their  deleterious  action  not  so  much  by  their  actual 
presence,  as  by  a  poison  or  ptomaine  that  they 
secrete  from  their  minute  bodies,  and  that  each 
specific  bacterium  or  bacillus  has  its  own  peculiar 
body-product  which,  in  the  case  of  pathogenic  or 


224  HYGIENE   OF  THE  SICK-ROOM. 

disease-producing  germs,  is  a  poison.  This  then 
complicates  the  struggle  between  the  bacteria  and 
the  body-cells.  There  is  then  an  actual  life-and- 
death  struggle  between  cells  and  bacteria.  Inoc- 
ulation of  a  frog  with  the  bacillus  anthracis  showed 
this  struggle  very  beautifully.  A  study  of  the  cells 
of  this  frog  revealed  them  with  bacilli  and  parts 
of  bacilli  within  the  cell-wall  in  process  of  digestion 
or  disintegration. 

"  Thus  there  is  good  reason  to  believe  that  in  the 
presence  of  a  contagious  or  infectious  disease,  the 
germs,  floating  about  or  in  some  way  gaining  access 
to  the  individual  near  by,  find  their  way  into  the 
body,  and  there  a  struggle  takes  place  between  them 
and  these  cells,  that  are  attacked  by  the  invaders. 
Now  begins  a  struggle  for  supremacy.  The  cells 
close  around  the  attacking  hosts  and  endeavor  to 
destroy  them  and  carry  them  off,  or  at  least  to  pre- 
vent the  further  ingress  of  the  bacteria.  If  the  cells 
are  victorious,  they  devour  the  germs,  carry  them 
away,  and  thus  the  individual  escapes  the  disease. 
But  if  the  germs  increase  too  rapidly,  and,  by  the 
secretion  of  the  poison  or  ptomaine  from  their 
bodies,  cause  the  death  of  the  cells,  then  sickness 


IMMUNITY  FROM  DISEASE.  225 

results.  In  this  case  the  accumulation  of  these 
carrier  cells  that  are  killed  by  the  germs  results 
in  suppuration,  for  the  cells  of  pus  are  but  the 
white  blood  corpuscles,  leucocytes,  or  phagocytes, 
when  dead.  As  heat  increases  the  motion  of  these 
carrier  cells  and  also  their  protective  activity,  the 
rise  of  temperature  that  precedes  and  accompanies 
suppuration  has  been  looked  upon  as  an  attempt 
on  the  part  of  Nature  to  assist  the  activity  of 
the  cells  and  to  destroy  the  invading  bacteria. 

"  Immunity  from  second  attacks  of  certain  dis- 
eases, as  well  as  the  protective  influence  of  certain 
inoculations  and  vaccinations,  has  never  been 
clearly  understood,  although  various  explanations 
have  of  late  been  offered.  In  all  probability, 
although  this  is  but  a  theory  sustained  by  an- 
alogy, after  recovery  from  the  contagious  disease, 
usually  occurring  but  once,  the  bacteria  are  sup- 
posed to  secrete  some  morbid  virus  that  hinders 
their  own  life,  just  as  animals  produce  carbonic 
acid  gas,  which  is  poisonous  to  them,  or  the  yeast- 
fermentation  produces  alcohol,  which  stops  the 
growth  of  this  fungus. 

"  In  the  same  way,  after  these  attacks,  the  cells 


226  HYGIENE   OF   THE  SICK-ROOM. 


of  the  body  are  supposed  to  contain  some  sub- 
stance that  resists  the  second  attack  of  those 
organisms.  The  strength  and  duration  of  this 
immunity  differs  in  individuals.  Of  course,  the 
ability  of  these  cells  to  struggle  with  bacteria 
is  lessened  in  weakened  individuals,  and  hence, 
for  example,  it  is  very  probable  that  the  lowered 
vitality  caused  by  being  chilled  below  the  re- 
cuperating point  invites  an  attack  of  pneumonia 
or  some  other  disease,  not  from  the  mere  chill- 
ing, but  from  the  weakening  of  the  strength  of 
the  cells.  In  hereditary  diseases  predisposition 
plays  an  important  role. 

"  We  thus  see  that  before  nature  succumbs 
or  yields  to  what  has  been  very  wisely  called 
an  '  attack '  of  a  disease,  she  uses  various 
means  of  defense — and,  fortunately  for  us,  often 
comes  off  victorious." 

This  explanation  of  Metschnikoff,  embodied 
in  the  article  just  quoted,  was  at  first  received 
with'out  question,  but  when  it  was  further  studied 
objections  began  to  be  brought  against  it,  and 
some  of  these  had  great  weight. 

A  fourth  explanation  of  immunity  is  advanced 


IMMUNITY  FROM  DISEASE.  227 

by  Buchner,  who  suggests  that  "  in  the  primary 
infection  from  which  the  animal  may  have  recov- 
ered there  has  been  produced  a  '  reactive  change  ' 
in  the  integral  cells  of  the  body  that  enables  them 
to  protect  themselves  against  subsequent  inroads 
of  the  same  organism." 

All  these  four  theories  have  some  ingredients 
of  plausibility,  and  it  is  probable  that  they  all,  com- 
bined or  singly,  at  different  times  are  true  in 
explaining  immunity.  In  general,  the  extremes 
of  life,  the  weak  and  the  sickly,  and  any  one  very 
much  fatigued  and  frightened,  become  an  easy 
prey  to  disease,  while  the  well  and  healthy  in  the 
same  condition  would  escape.  The  protection 
acquired  in  vaccinations,  as  in  small-pox,  in  hydro- 
phobia, and  as  Koch  intended  his  tuberculin  to 
act,  is  supposed  to  be  according  to  the  retention 
theory. 

It  is  of  interest  to  add  that  some  recent  work 
on  pneumonia  has  shown  that  in  the  beginning 
of  the  disease  and  up  to  the  time  of  the  crisis 
there  is  circulating  in  the  blood  of  the  patient  a 
certain  poison,  which  has  been  called  pneumo- 
toxine,  and  which  is  very  likely  produced  by 


228  HYGIENE   OF  THE  SICK-ROOM. 

the  pneumococcus  or  bacillus  of  pneumonia. 
After  the  crisis  this  pneumotoxine  disappears,  and 
a  new  substance  which  was  not  there  before  is  now 
found  in  the  blood. 

Experiments  on  animals  and  also  on  patients 
would  seem  to  indicate  that  this  new  substance 
which  appears  in  the  blood  after  the  crisis,  in 
reality  causes  the  crisis,  and  is  the  result  of  the 
struggle  of  the  cells  to  overcome  the  poison 
produced  by  the  pneumonia  bacillus.  The  con- 
solidation of  the  lung  substance  and  the  immense 
amount  of  fibrinous  matter  which  is  found  in  the 
air  spaces  of  the  lungs  in  a  certain  stage  of 
pneumonia  is  supposed  to  be  an  attempt  on  the 
part  of  Nature  to  erect  a  barrier  against  this  in- 
vading host  and  the  poison  produced  by  it,  from 
getting  on  to  the  lungs  and  then  into  the  whole 
body.  If  we  have  not  cleared  up  this  subject 
fully  and  satisfactorily  it  shows  that  we  are  on 
the  right  track,  and  in  a  few  years,  if  not  sooner,  we 
may  expect  to  have  practical  results  from  these 
apparently  useless  experiments. 

If  we  can  find  out  what  this  substance  is  that  is 
found  in  the  blood  of  pneumonia  patients  after  the 


IMMUNITY  FROM  DISEASE.  229 

crisis,  and  can  produce  it  artificially  and  introduce 
it  into  the  system  of  pneumonia  patients  early  in 
the  course  of  the  disease  and  cut  it  short,  we  shall 
be  reaping  very  valuable  and  practical  results  from 
the  laboratory. 


CHAPTER  XXI. 

FOOD. 

The  subject  of  diet  has  not  entered  sufficiently 
into  the  education  of  the  physicians  of  the  United 
States,  and  the  important  question  of  dietetics  is 
too  often  left  to  be  learned  by  experience  in  the 
course  of  practice  ;  consequently,  it  will  be  noticed 
in  America  that  the  physician  gives  directions  as 
to  the  drugs  and  medicines,  but  his  orders  as  to 
what  the  patient  shall  take  for  nourishment 
and  refreshment  are  very  vague  and  often  un- 
satisfactory. Now,  if  there  is  one  thing  important 
above  all  other  things  in  the  treatment  of  most 
diseases,  and  especially  in  lingering  and  wasting 
diseases,  it  is  what  the  patient  should  have  and 
what  should  be  withheld.  The  very  fact  that  the 
nurse  is  given  general  directions  in  so  many 
cases  is  sufficient  reason  why  she  should  know 
something  about  the  food  she  gives. 

Too  much  or  too  little  food,  bad  food,  food 
improperly  cooked,  may  all  pave  the  way  to 
230 


FOOD.  231 

disease,  even  when  the  body  is  in  a  state  of 
health.  How  much  more  important  is  it,  then, 
in  sickness  to  give  specific  directions  about  the 
food  to  be  taken,  and  to  carry  these  directions 
out  with  intelligence?  Of  course,  it  should  be 
remembered  that  personal  taste  should  always 
be  consulted  in  giving  food  to  an  invalid,  and 
that  distasteful  food  forced  on  a  patient  too  often 
disagrees,  all  physiological  reasons  to  the  contrary. 
The  very  fact  that  a  patient  expresses  a  desire 
for  a  certain  thing  will  help  to  digest  it. 

From  improper  food  may  come  inflammation 
and  congestion  of  the  digestive  tract,  which  may 
favor  the  growth  and  increase  of  dangerous 
bacilli  in  the  intestines.  In  this  way  typhoid 
fever,  Asiatic  cholera,  diarrhoea,  dysentery,  and 
even  tuberculosis  may  find  an  entrance  into  the 
system.  The  careful  selection  of  food  well  chosen 
may  correct  this  disordered  state  of  affairs  and  cure 
the  disease  with  little  need  of  drugs. 

Milk,  especially  human  milk,  is  the  most  perfect 
food  known,  containing,  as  it  does,  all  the  neces- 
sary ingredients  for  nourishment ;  hence,  it  is  used 
in  infancy  in  health,  and  in  adult  life  in  many  dis- 


232  HYGIENE   OF  THE  SICK-ROOM. 


eases.  In  large  cities  the  milk  is  too  often  adul- 
terated and  poor.  The  most  usual  adulteration  is 
made  by  adding  water  and  then  stirring  in  meal. 
Several  instruments  have  been  invented  to  test  the 
purity  of  milk,  but  they  are  not  so  reliable  and 
easy  to  handle  that  the  average  householder 
can  use  them  with  satisfaction.  Thin,  diluted 
milk  has  a  pale  blue  color  and  a  poor  taste,  and 
such  milk  is  more  fluid  than  it  should  be.  The 
Germans  use  the  "  Nagelprobe,"  which  is  carried 
out  by  dropping  a  little  milk  on  the  thumb  nail, 
and  seeing  if  the  milk  will  remain  suspended  from 
it  when  the  nail  is  held  down.  Good  milk  is  con- 
sistent enough  to  stay  on  the  nail,  while  thin  milk 
will  run  off.  . 

As  the  sick  usually  digest  slowly,  milk  should 
be  given  in  small  quantities  and  at  short  intervals. 
Many  persons  think  that  the  mere  putting  of  food 
into  the  stomach  is  sufficient.  The  nurse  should 
know  that  it  is  the  digestion  and  assimilation  of 
food  that  strengthens  and  helps  the  patient.  Too 
much  poured  into  a  weak  stomach  is  either 
vomited  or  passes  out,  causing  a  diarrhoea.  It 
is  often  necessary  to  add  an  alkali  to  milk  to 


FOOD.  233 

correct  that  acidity  which  it  is  so  hard  for  some 
stomachs  to  endure.  The  most  common  addition 
is  lime  water.  This  may  be  added  in  the  propor- 
tion of  one  part  to  three  or  four  of  milk.  As  mas- 
tication is  not  needed  to  swallow  milk,  the  tongue 
in  a  milk  diet  soon  becomes  very  white,  not  only 
on  account  of  the  collection  of  epithelium  scales, 
but  because  the  milk  whitens  the  tongue.  The 
globules  which  rise  to  the  surface  of  milk 
on  standing  form  the  cream,  and  when  this  is 
skimmed  off  the  residue  is  called  skim-milk. 
This  is  sometimes  used  when  the  system  is  so 
weakened  that  it  cannot  digest  the  fatty  globules 
of  the  cream. 

When  milk  is  given  for  a  long  time  it  palls  on 
the  patient,  and  then  it  ceases  to  do  good.  For 
this  reason  it  should  be  given  intermittently,  when 
there 'is  a  prospect  of  its  being  used  for  a  long 
time,  for  when  it  cannot  be  borne  it  is  exceed- 
ingly difficult  to  find  a  good  and  suitable  substi- 
tute for  it.  As  has  been  mentioned  in  another 
place,  milk  is  not  only  a  good  food,  but  it  is  a 
good  medium  in  which  disease  germs  can  live  and 

grow.     For  this  reason,  milk  for  the  sick  and  the 
16 


234  HYGIENE   OF  THE  SICK-ROOM. 

young  should  be  used  only  from  the  most  reliable 
sources,  and  when  there  is  doubt  the  milk  should 
be  sterilized.  By  sterilization  is  meant  the  expos- 
ing of  milk  in  a  covered  vessel  to  steam  for  twenty 
to  thirty  minutes,  until  all  germs  in  it  are  destroyed. 
When  there  is  any  doubt  as  to  the  purity  of  the 
milk,  condensed  milk  has  been  suggested  as  a  sub- 
stitute, but  sterilized  milk  is  to  be  preferred,  and 
sterilizers  are  so  simple  and  cheap  that  they  may 
be  owned  by  every  family  in  which  there  are  chil- 
dren or  invalids  using  much  milk,  or  a  sterilizer 
may  be  improvised. 

Koumyss,  which  is  fermented  milk,  usually 
mare's  milk,  has  been  used  with  great  success 
in  cases  of  dyspepsia.  It  is  very  grateful  to  the 
stomach  and  can  be  taken  in  large  quantities,  and 
it  increases  the  weight  very  rapidly.  In  weakened 
conditions  of  the  stomach  it  will  often  be  necessary 
for  the  nurse  to  predigest  the  milk.  This  may  be 
done  by  adding  some  form  of  pepsin.  Fairchild's 
peptonizing  tubes  are  especially  good,  but  give  the 
milk  a  very  unpleasant  flavor. 

The  efficacy  of  beef  tea  has  been  frequently 
called  in  question  of  late.  In  this  connection  it 


FOOD.  235 

should  be  remembered  that  not  all  that  is  poured 
into  the  stomach  of  an  invalid  will  give  strength. 
The  beef  tea,  like  all  other  foods,  to  do  good  must 
be  digested  and  assimilated.  It  is  not  uncommon 
to  notice  the  beef  tea  floating  on  top  of  the  stools 
of  an  invalid,  and  this  is  especially  true  when  a 
diarrhoea  has  been  set  up  by  the  frequent  feeding 
with  beef  tea.  Many  of  the  beef  extracts  on  the 
market  are  of  no  use,  and  the  apparent  good  results 
are  more  imaginary  or  a  matter  of  tradition  than 
actual.  Many  of  these  so-called  foods  are  given 
warm,  and  the  heat  of  the  food  alone  acts  as  a 
stimulant  and  brightens  up  the  patient  for  the 
time.  Hot  water  would  often  have  the  same 
effect.  Chicken,  rice,  and  other  soups  are  bland 
and  pleasant  and  may  give  some  strength.  All 
these  soups  and  broths  are  better  made  at  home 
by  the  nurse  than  bought  outside.  The  good 
nurse  should  understand  the  practical  side  of 
cooking. 

There  is  nothing  that  takes  the  place  of  water 
as  a  quencher  of  thirst.  Milk,  which  normally 
contains  87  per  cent,  of  water  and  most  usually 
more,  is  very  near  water  as  a  quencher  of  thirst. 


236  HYGIENE   OF   THE  SICK-ROOM. 


Young  infants  often  cry  because  they  are  thirsty 
and  would  readily  take  water  instead  of  the  milk 
if  the  former  were  offered  to  them.  Most  nurses 
never  think  that  infants  may  become  thirsty.  The 
sick  often  crave  for  water,  and  this  craving  is  par- 
ticularly marked  when  the  disease  is  one  that 
causes  much  water  to  be  lost  from  the  body. 
Thus  in  all  diarrhceal  diseases,  in  all  fevers,  and 
in  all  cases  in  which  the  fluids  are  withdrawn  from 
the  body  in  excess,  the  thirst  is  very  great.  At 
one  time  it  was  considered  very  bad  practice  to 
give  water  in  these  conditions,  but  now  it  is 
conceded  by  all  modern  practitioners  of  medicine 
that  this  loss  of  fluid  from  the  body  should  be 
made  up.  The  water  in  every  case  should  be 
given  with  great  caution.  In  fevers  the  excessive 
thirst  should  be  quenched  with  slightly  acidulated 
drinks  or  with  water  given  with  a  teaspoon. 
Cracked  ice  is  very  grateful  and  by  melting  in 
the  mouth  quenches  the  thirst  of  a  fever  patient 
better  than  water.  In  diarrhceal  diseases  in  which 
there  is  no  fever,  water  should  be  given  very 
sparingly,  but  enough  to  make  up  for  the  waste. 
As  all  foods  contain  water  in  some  proportion,  the 


FOOD.  237 

patient  takes  water  with  almost  everything.  Per- 
sons in  health  often  pride  themselves  on  the  small 
amount  of  water  they  take.  This  in  part  is  a 
matter  of  taste,  but  it  is  undoubtedly  better  to 
take  water  through  the  day  and  even  at  meals. 

However  dear  to  the  heart  of  the  patient  or 
the  nurse,  or  even  the  doctor,  the  subject  of  pro- 
hibition may  be,  it  should  never  be  forgotten  that 
alcohol  and  its  derivatives  are  often  very  im- 
portant in  the  sick-room,  provided  they  are  used 
with  that  precaution  necessary  in  the  case  of  all 
dangerous  drugs.  It  may  be  stated  at  the  outset 
that  whisky,  wines,  etc.,  are  not  tonics,  but  stimu- 
lants, and  when  used  it  is  because  their  effects  are 
desired  immediately.  They  should  always  be 
used  with  extreme  caution  in  the  young  of  both 
sexes  where  there  may  be  danger  of  forming  a 
dangerous  habit.  On  the  principle  that  stolen 
fruits  are  the  sweetest,  many  persons,  especially 
young  men  who  have  heard  of  the  horrors  of 
drink,  take  the  first  opportunity  to  test  the  danger 
of  drinking  and  learn  to  like  a  liquid  which  they 
would  not  have  been  tempted  to  use  if  it  had  not 
been  prohibited. 


238  HYGIENE   OF  THE  SICK-ROOM. 

The  nurse  and  the  parents  should  never  forget 
that  the  best  stimulants  are  the  strongest,  and  on 
the  principle  of  not  sending  a  boy  to  do  a  man's 
work,  they  should  administer  whisky  or  brandy 
where  sudden  stimulation  is  needed.  A  very  com- 
mon combination  is  whisky  and  milk.  In  typhoid 
fever  and  such  wasting  diseases,  a  half  glass  of 
milk  to  which  two  tablespoonfuls  of  whisky  have 
been  added  should  be  given  every  hour  if  they 
are  assimilated.  The  whisky  does  the  stimulating 
and  the  milk  nourishes.  The  various  wines  are 
good  in  convalescence,  and  champagne  is  highly 
recommended  when  an  irritable  stomach  rejects 
all  other  things.  Ale  and  beer  are  too  heavy  for  a 
weak  stomach,  but  in  sleeplessness  a  glass  of  beer 
at  bedtime  will  often  bring  the  required  rest. 
Brandy  is  more  astringent  than  whisky,  and  hence 
the  former  should  be  preferred  in  diarrhoeal 
diseases. 

Tea  and  coffee  are  very  useful  stimulants  and 
universally  used,  but  they  are  the  causes  of  many 
conditions  of  dyspepsia  and  have  undoubtedly  done 
much  harm.  A  cup  of  black  coffee  after  a  hearty 
dinner  undoubtedly  acts  as  an  aid  to  digestion, 


FOOD.  239 

but  the  too  constant  use  of  coffee  and  tea  reacts 
very  dangerously  on  the  nerves.  The  effects  of 
tea  are  especially  noticeable  on  women  of  the 
poorer  classes,  who  tipple  tea  the  whole  day  long 
because  they  cannot  get  enough  to  eat.  The 
contact  of  the  astringent  tea  with  the  mucous 
membrane  of  the  empty  stomach  soon  causes  a 
condition  of  tanning,  so  that  the  secretion  of  the 
gastric  juice  is  interfered  with  and  the  lining  of 
the  stomach  is  tanned  and  hard,  and  dyspepsia  is 
the  result.  Coffee  is  not  quite  as  dangerous  as  tea, 
but  the  continued  use  of  coffee  brings  on  a  condi- 
tion of  "  nervousness  "  which  it  is  very  hard  to 
get  rid  of.  In  this  connection  it  might  be  well  to 
say  that  the  staying  properties  of  coffee  are  much 
greater  than  those  of  alcoholics.  Thus  of  two 
men  doing  the  same  kind  of  hard  work  or  indulg- 
ing in  a  walk  of  a  long  distance  for  a  wager,  the 
one  who  takes  coffee  outlasts  by  far  the  one  who 
looks  to  whisky  or  brandy  for  strength. 

The  amount  of  nourishment  in  chocolate  is 
very  great.  Travelers  who  walk  long  distances 
or  who  go  sight-seeing  and  become  fatigued  find 
a  piece  of  hard  chocolate  of  great  use  as  a  food. 


240  HYGIENE   OF  THE  SICK-ROOM. 

Invalids  cannot  always  stand  cocoa  or  chocolate 
they  are  too  weak,  for  the  large  amount  of  fat  in 
this  substance  makes  it  too  rich  for  them.      When 
deprived  of  some  of  its  fat  it  is  a  very  useful  sub- 
stitute for  tea  or  coffee. 

When  there  is  no  special  aversion  to  them,  eggs 
form  a  very  important  article  of  diet  in  the  sick- 
room. White  of  egg  beaten  up  to  a  delicate 
froth,  put  into  a  glass  into  which  a  tablespoonful 
or  two  of  whisky  is  poured,  and  slightly  sweet- 
ened makes  a  very  pleasant,  and  refreshing  tonic 
and  stimulant  for  the  sick  when  the  powers  are 
flagging.  A  soft-boiled  egg  agrees  with  many 
persons,  and  an  egg  boiled  hard  and  crushed  with 
the  back  of  a  spoon  is  generally  very  soon  taken 
up  by  the  system. 

Meats  should  not  be  given  until  convalescence 
is  well  under  way.  The  best  meats  are  beef  and 
fowl.  Chicken  broiled  or  boiled  until  the  flesh 
drops  off  the  bones  is  very  digestible.  Beef  is 
also  digestible  and  nourishing.  A  small  piece  of 
steak  cut  thick  and  broiled  quickly  over  a  hot  fire, 
and  then  delicately  seasoned,  makes  a  very  attract- 
ive dish  for  one  able  to  sit  up.  Of  the  other  meats 


FOOD.  241 

mutton  is  better  than  veal,  and  pork  should  never 
be  used.  In  fact,  all  fat  meats  and  all  meats  fried 
are  as  poison  to  the  stomach  of  an  invalid,  and 
often  to  a  well  person. 

Stale  bread  and  toast  are  better  borne  by  a  weak 
stomach  than  fresh  bread  and  hot  breads  of  any 
kind.  Of  the  various  vegetables,  the  starchy  ones 
are  the  most  objectionable,  and  many  of  the  fresh 
ones  are  too  indigestible  for  a  weak  stomach. 
Raw  oysters  are  more  easily  borne  than  any  other 
food,  provided  the  individual  has  no  especial 
dislike  to  them.  Fish  is  just  as  well  excluded  from 
the  diet  list  of  an  invalid.  The  various  jellies  are 
very  pleasant  to  the  stomach,  but  they  are  of 
doubtful  use  and  are  more  valued  by  the  laity  than 
by  the  profession. 

The  friends  of  the  sick  are  in  the  habit  of  send- 
ing all  manner  of  things  that  the  invalid  cannot 
possibly  eat,  and  it  is  the  duty  of  the  nurse,  in  the 
absence  of  the  physician,  to  say  positively  what 
shall  be  allowed  and  what  prohibited.  Fruits 
should  be  admitted  into  the  sick-room  with  the 
greatest  caution.  While  the  juice  of  an  orange  is 
very  refreshing  and  generally  free  from  danger, 


242  HYGIENE   OF  THE  SICK-ROOM. 

the  pulp  is  hard  even  for  a  healthy  person  to 
bear.  Bananas  are  also  extremely  indigestible,  and 
a  strict  quarantine  should  be  kept  against  them. 

Of  course,  these  outlines  of  diet  are  not  suffici- 
ent to  guide  the  nurse,  but  she  should  add  to  them 
by  a  practical  course  in  the  kitchen ;  for  a  good 
nurse  should  be  a  good  cook  and  be  able  to  do 
anything  that  will  help  the  recovery  of  her 
patient.  Much  good  food  is  spoiled  by  bad  cook- 
ing or  by  a  bad  fire,  and  the  only  way  to  understand 
all  these  difficulties  is  to  have  practical  experience 
in  the  kitchen.  The  few  hints  given  here  may 
help  the  nurse  in  the  right  direction,  and  she  can 
fill  up  the  gaps  by  study  in  physiology,  cooking, 
and  other  branches. 

In  such  diseased  conditions  as  diabetes,  dyspep- 
sia, diarrhoea,  dysentery,  constipation,  and  other 
diseases  a  special  diet  is  needed.  This  the  nurse 
cannot  learn  from  such  a  book  as  this.  She  must 
follow  the  exact  directions  of  the  physician,  and 
note  that  while  the  general  plan  of  each  one  of 
these  conditions  is  alike,  each  case  will  need 
special  study,  and  no  fast  rules  of  diet  for  it  can  be 
laid  down. 


INDEX. 


Abbott,  A.  C.,  214 
Air,  bacteria  in,  32 

bad,  predisposing   to   con- 
sumption, 198 
bad,  from  sewers,  194 
composition  of,  189 
effects  of  bad,  197 
Alcoholics,  237 
Amoeboid  movements,  221 
Animals,  carriers  of  diphtheria, 

no,  in,  115,  116,  117 
carriers  of  tuberculosis,  74 
Antiseptic,  31,  52,  53,  154 

surgery,  rules  in,  157,  161, 

167 

Antisepsis,  147,  148,  154,  161 
Asepsis,  147,  149,  154,  161 
Aseptol,  44 
Asiatic  cholera,  87 
bacilli  of,  33 

fright   and   fatigue  an  ele- 
ment in  causing,  89 
prevention  and  treatment  of, 

90,  91,  92 

theory  of  prevention  of,  89, 
90 

Bacilli,  13 

Bacillus  of  typhoid  fever,  77 
Bacteria,  II,  13 

in  the  air,  32 

benefits  of,  18,  19 

calculation  of  the  number 
of,  150 


Bacteria  in  cemeteries,  34 
classification  of,  16 
cultivation  of,  22,  23 
destruction  of,  25 
in  dust,  20,  161,  216 
entrance  of,  into  the  system 
through  the  breathing  ap- 
paratus, 32 
in  food,  37 
in  ice,  25,  38 
manner  of  growth  of,  17 
methods  of  study  of,  20 
in  milk,  38 
of  the  mouth,  174 
number  of  in  places,  32 
size  of,  17 
in  the  soil,  33 
spores  of,  viable  in  ice,  25 
staining  of,  21,  22 
of  surgical  diseases,  146 
in  water,  32,  38,  39 

Bacteriology,  II,  13,  14 

Barometer,  190 

Beef  tea,  234 

Blindness,  causes  of,  183 

Bread,  241 

Buchner,  227 


Camp  fever,  see  typhus  fever,  85 
Cemeteries,  infection  from,  34 
Chocolate,  239 
Cleanliness,  13,  31,  155 
Clothing,  disinfection  of,  58 


243 


244 


INDEX. 


Coffee,  238 
Communicable,  28 
Consumption,     predisposed    by 

bad  air,  198 
pulmonary,  65 
Contagious,  27,  29 
Credi,  184 
Creolin,  44 


Deodorant,  31,  52 
Diarrhrea  caused  by  heat,  199 
Diphtheria,  30,  107 
bacillus  of,  108 
character  of,  108 
carried    by    animals,    no, 

in,  115,  116,  117 
by  dust,  114 

by  milk,  111,115,  116,  121 
prevention  of,  1 1 8 
Disease,  immunity  and   protec- 
tion from,  213 
predisposed  by  fatigue  and 

fright,  39,  227 
Disinfectant,  31,  53 

bichloride  of  mercury   not 

always  reliable  as  a,  42 
fire  as  a,  40 

heat,  dry  and  moist  as  a,  41 
Disinfectants,  report  of  the  com- 
mittee  on,  of   the  American 
Public  Health  Association,  45 
Disinfecting,  methods  of,  40 
Disinfection,  40 
chemical,  42 
of  clothing,  bedding,  etc., 

48,58 

of  the  dead,  49 
and  disinfectants,  51 
of  excreta,  47,  55 
of  faeces,  43 
of  furniture,  etc.,  49 
of  ingesta,  63 


Disinfection,  mechanical,  44 

of  the  person,  49,  57 

physical,  40 

of  privy-vaults,  cess-pools, 
etc.,  62 

of  the  sick-room  and  hos- 
pital wards,  50,  59 

of  the  skin,  172 

of  typhoid  stools,  So,  8 1 
Drinking  water  a  cause  of  chol- 
era, 88,  89 

a   cause    of  typhoid  fever, 

77,78 

Dust  predisposing  to  tuberculosis, 
68,  70,  73 

bacteria   in,    20,  151,  161, 
216 

carried  long  distances,  33 

carrying  diphtheria,  114 

containing  bacteria,  20, 151, 
161,  216 

a  conveyer  of  bacteria,  20, 
151,  161,  216 

dangerous      in      an     ideal 
operating  room,  149 

Eberth,  77 
Eggs,  240 
Endemic,  29 
Epidemic.  29 

influenza     complicated    by 

pneumonia,  134 
Erysipelas,  30 

organism  of,  155 
Esmarch,  44 
Excreta,  disinfection  of,  43,  55 

Faeces,  disinfection  of,  43,  55 
Fatigue   an  element  in  causing 

Asiatic  cholera,  89 
predisposing  to  disease,  39, 
227 


INDEX. 


245 


Fire  as  a  disinfectant,  40 
Fish,  241 

Flies,  carriers  of  contagion,  37 
Food,  230 

bacteria  in,  32,  37 
infected,   causing    tubercu- 
losis, 70 
infected,    causing    typhoid 

fever,  78 
Fright   an   element   in    causing 

Asiatic  cholera,  89 
Fruits,  241 

Fumigation,  with    sulphur,   6l, 
123 


Gaff  ky,  77 
Center,  152,  157 
Gonococcus,  182 
Grippe,  133 


Heat  causing  diarrhoea,  199 
dry  and  moist  as  a  disinfect- 
ant, 41 

Heating,  methods  of,  208 
Hospital  fever,  see  typhus  fever, 
85 


Ice,  impure,  a  cause  of  typhoid 

fever,  25,  38,  79 

Immunity  and  protection  from 
disease,  213 

theories  of,  214 
Incubation,  stage  of,  30 
Infection  and  disinfection,  27 

from  cemeteries,  34 

modes  of,  32 

prevention  of,  35 
Infectious,  27,  29 

disease,  hereditary,  38 
Infective,  28 


Influenza,  epidemic,  133 
Inoculable,  28 
Inoculation,  24 
Iodine,  trichloride  of,  44 

Jacobi,  122 

Jail  fever,  see  typhus  fever,  85 
Jellies,  241 

Johns  Hopkins  Hospital,  209 
Pathological  Laboratory,  42 

Kennan,  George,  197 
Klebs,  1 08 

Koch,  1 6,  17,  23,  65,  88,  227 
Koumyss,  234 

Laveran,  143,  144 
Leeu-wenhoek,  14 
Lister,  Sir  Joseph,  146 
Loeffler,  1 08 

Malaria,  25,  30,  141 

organism  of,  32,  35,  144 
Materies  morbi,  II,  30,  77 
Measles,  30,  103 

black,  104 

Mercury,      bichloride     of,     not 
always  reliable  as  a  dis- 
infectant, 42 
Metastases,  149,  157 
Mftsfhnikoff,  215,  226 
Miasmatic-contagious,  29,  131 
Micrococci,  13 
Midwives,  advice  to,  185 
Milk,  231,  235 

carrying    diphtheria,     in, 
115,  116,  121 

carrying  scarlet  fever,  95 
Mouth,  bacteria  of  the,  174 
Mutter,  Otto  Friedrich,  15 


246 


INDEX. 


New  York  Health  Board,  72, 
97 

Occupations,  dangerous,  195 
Operating  room,  the  ideal,  150 
Ophthalmia  neonatorum,  182 
prevention    and    treatment 

of,  184 
Owen,  Frederick  N.,  209 

Pandemic,  29 

Parkes,  82,  209 

Pasteur,  16,  17,  214 

Person,  disinfection  of  the,  57 

Pertussis,  see  whooping  cough, 

139 

Pfuhl,  43 

Phagocyte,  220,  225 
Pneumonia,  136 

a  complication  of  epidemic 
influenza,  134 

diplococcus  of,  136 
Pneumotoxine,  227 
Ptomaines,  149,  223,  224 
Pyaemia,  157 

organism  of,  155 

Roberts,  John  B.,  160 

Scarlatina,  see  scarlet  fever,  30, 

93 

communicability  of,  94 
Scarlet  fever,  see  scarlatina,  30, 

93 

caused  by  milk,  95 
prevention    and    treat- 
ment of,    loo,  101, 
1 02 

surgical    and   obstetri- 
cal, 97 
Septicaemia,  157 

organism  of,  155 


Sewers,  importance  of,  36 
Ship  fever,  see  typhus  fever,  85 
Sick-room,  disinfection  of,  59 
Skin,  disinfection  of  the,  172 
Smallpox,  see  variola,  30,  128 

prevention  of,  129 
Smith,  J.  Lewis,  97,  123,  127, 

129 

Soil,  bacteria  in  the,  33 
Spontaneous  generation,  15 
Spotted  fever,  see  typhus  fever, 

85 

Squibb,  E.  R.,  124 
Staphylococcus,  white,  166 
Sterilization,  148,  234 
Sulphur  fumigation,  123 
Suppuration,  156,  157 
organisms  of,  155 
Surgical  diseases,  bacteria  of,  146 


Tape  worm,  38 
Tea,  238 

Teeth,  decay  of  the,  175 
Tetanus,  bacilli  of,  34 
Thrush,  175 

prevention  and  treatment  of, 

176,  177,  178 

Tommasi  Crudeli,  142,  143 
Tongue,  178 

care  of  the,  1 80,  181 
Torricelli,  190 
Trained   nurse,   importance    of 

the,  9 
compared     with     religious 

sister,  71 
Tuberculosis,  65 

spread  by  animals,  74 
bacillus  of,  33,  65,  66 

advantage  of  the  dis- 
covery of,  66 
prevention  of  the  spread 
of,  67 


INDEX. 


247 


Tuberculosis,  caused  by  inhala- 
tion, 70 

disposal  of  the  expectora- 
tion in,  68 

predisposed  by  dust  inhala- 
tion, 68,  70,  73 
from  infected  food,  70 
identity  of,  65 
prevention  of,  72 
of  the  stomach,  70 
Typhoid  bacillus,  77,  78 
fever,  30,  76 

bacilli  of,  33 
caused      by     infected 
drinking  water,  77, 
8l 
caused      by     infected 

food,  78 
caused  by  infected  ice, 

25,38 
infected  water  a  cause 

of,  39 
caused  by  water-closet 

in  bad  repair,  83 
stools,  disinfection  of, 

80,  81 
Typhus  fever,  30,  85 


Vaccination,  128 
Variola,  see  smallpox,  30,  130 
Varioloid,  30,  130 
Ventilation  and  heating,  188 
methods  of,  202 


Water,  235 

bacteria  in,  32,  38 
closets  in  bad  repair  caus- 
ing typhoid  fever,  83 
dangers  of  river,  82 
infected,  a  cause  of  typhoid 

fever,  39 
Welch,  Wm.  H.,  34,  112,  165, 

1 66,  201 
Will,  14 

Whooping   cough  see  pertussis, 
139 


Yellow  fever,  131 
Zinc,  chloride  of,  44 


94 


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